Healthcare Provider Details

I. General information

NPI: 1366484651
Provider Name (Legal Business Name): GEORGE CIRESI III D.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 PATCHOGUE YAPHANK RD
EAST PATCHOGUE NY
11772-4899
US

IV. Provider business mailing address

191 PATCHOGUE YAPHANK RD
EAST PATCHOGUE NY
11772-4899
US

V. Phone/Fax

Practice location:
  • Phone: 631-775-0971
  • Fax: 631-475-0975
Mailing address:
  • Phone: 631-775-0971
  • Fax: 631-475-0975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number025766-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: