Healthcare Provider Details

I. General information

NPI: 1679801559
Provider Name (Legal Business Name): TZANWEI FANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2009
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 E MAIN ST SUITE 18
EAST ISLIP NY
11730-2800
US

IV. Provider business mailing address

369 E MAIN ST SUITE 18
EAST ISLIP NY
11730-2800
US

V. Phone/Fax

Practice location:
  • Phone: 631-277-1600
  • Fax: 631-277-1638
Mailing address:
  • Phone: 631-277-1600
  • Fax: 631-277-1600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number258587
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD70349
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: