Healthcare Provider Details

I. General information

NPI: 1538114707
Provider Name (Legal Business Name): STONY BROOK UROLOGY, UNIVERSITY FACULTY PRACTICE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 RESEARCH WAY SUITE 500
EAST SETAUKET NY
11733-3487
US

IV. Provider business mailing address

PO BOX 1554
STONY BROOK NY
11790-0988
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-6270
  • Fax:
Mailing address:
  • Phone: 631-444-1252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: WAYNE WALTZER
Title or Position: CHAIR PERSON
Credential: M.D.
Phone: 631-444-1252