Healthcare Provider Details

I. General information

NPI: 1184290892
Provider Name (Legal Business Name): FAZLE SHOWON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BROADHOLLOW RD STE 106
FARMINGDALE NY
11735-4813
US

IV. Provider business mailing address

100 BROADHOLLOW RD STE 106
FARMINGDALE NY
11735-4813
US

V. Phone/Fax

Practice location:
  • Phone: 631-693-6644
  • Fax:
Mailing address:
  • Phone: 631-693-6644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number321826
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number321826
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: