Healthcare Provider Details

I. General information

NPI: 1366743239
Provider Name (Legal Business Name): VASCULAR DIAGNOSTICS OF LI PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 COMMACK RD SUITE 125
COMMACK NY
11725-6021
US

IV. Provider business mailing address

283 COMMACK RD SUITE 125
COMMACK NY
11725-6021
US

V. Phone/Fax

Practice location:
  • Phone: 631-499-3505
  • Fax:
Mailing address:
  • Phone: 631-499-3505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number119661
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number119661
License Number StateNY

VIII. Authorized Official

Name: DR. LATEEF GIWA
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 516-695-7172