Healthcare Provider Details

I. General information

NPI: 1568791663
Provider Name (Legal Business Name): 1 MILLER MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2009
Last Update Date: 12/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MILLER RD
FARMINGDALE NY
11735-2015
US

IV. Provider business mailing address

1 MILLER RD
FARMINGDALE NY
11735-2015
US

V. Phone/Fax

Practice location:
  • Phone: 516-755-5855
  • Fax: 516-755-0330
Mailing address:
  • Phone: 516-755-5855
  • Fax: 516-755-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number188292
License Number StateNY

VIII. Authorized Official

Name: STEVEN WONG
Title or Position: PRESIDENT
Credential: DO
Phone: 516-755-5855