Healthcare Provider Details

I. General information

NPI: 1619962966
Provider Name (Legal Business Name): MARTIN AJAX CHRISPHONTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 09/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 FULTON ST
FARMINGDALE NY
11735-3642
US

IV. Provider business mailing address

750 FULTON ST
FARMINGDALE NY
11735-3642
US

V. Phone/Fax

Practice location:
  • Phone: 631-249-2765
  • Fax: 631-249-3617
Mailing address:
  • Phone: 631-249-2765
  • Fax: 631-249-3617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME85871
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number190294
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number190294
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: