Healthcare Provider Details

I. General information

NPI: 1790780724
Provider Name (Legal Business Name): MICHAEL JOSEPH DEMARIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MEDICAL PLZ SUITE 303
GLEN COVE NY
11542-2101
US

IV. Provider business mailing address

10 MEDICAL PLZ SUITE 303
GLEN COVE NY
11542-2101
US

V. Phone/Fax

Practice location:
  • Phone: 516-676-0239
  • Fax: 516-676-0956
Mailing address:
  • Phone: 516-676-0239
  • Fax: 516-676-0956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number160671
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: