Healthcare Provider Details

I. General information

NPI: 1518232115
Provider Name (Legal Business Name): DEER PARK MEDICAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 DEER PARK AVE
DEER PARK NY
11729-1319
US

IV. Provider business mailing address

2103 DEER PARK AVE
DEER PARK NY
11729-1319
US

V. Phone/Fax

Practice location:
  • Phone: 631-242-4500
  • Fax: 631-617-6633
Mailing address:
  • Phone: 631-242-4500
  • Fax: 631-617-6633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL DEMISHEV
Title or Position: PC OWNER
Credential: M.D.
Phone: 631-242-4500