Healthcare Provider Details

I. General information

NPI: 1558392746
Provider Name (Legal Business Name): ROBERT F RUGGIERO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E MAIN ST
EAST ISLIP NY
11730-2600
US

IV. Provider business mailing address

126 E MAIN ST
EAST ISLIP NY
11730-2600
US

V. Phone/Fax

Practice location:
  • Phone: 631-581-0090
  • Fax: 631-581-2879
Mailing address:
  • Phone: 631-581-0090
  • Fax: 631-581-2879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number124710
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: