Healthcare Provider Details

I. General information

NPI: 1306803036
Provider Name (Legal Business Name): ROBERT ANTHONY DIMINO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 COMMUNITY DR
GREAT NECK NY
11021-5502
US

IV. Provider business mailing address

1983 MARCUS AVE LONG ISLAND JEWISH MEDICAL CTR
LAKE SUCCESS NY
11042-1016
US

V. Phone/Fax

Practice location:
  • Phone: 516-465-1900
  • Fax: 516-465-1830
Mailing address:
  • Phone: 516-802-6121
  • Fax: 516-616-5801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number016046
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number034052
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: