Healthcare Provider Details

I. General information

NPI: 1376833731
Provider Name (Legal Business Name): FARMINGDALE MEDICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FULTON STREET
FARMINGDALE NY
11735-2518
US

IV. Provider business mailing address

101 FULTON STREET
FARMINGDALE NY
11735-2518
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN WAT
Title or Position: OWNER
Credential: DO
Phone: 516-755-5855