Healthcare Provider Details

I. General information

NPI: 1366589186
Provider Name (Legal Business Name): DWIGHT DE RISI, M.D. FACS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 NORTHERN BLVD
GREAT NECK NY
11021-5306
US

IV. Provider business mailing address

1010 NORTHERN BLVD SUITE 102
GREAT NECK NY
11021-5306
US

V. Phone/Fax

Practice location:
  • Phone: 516-487-8888
  • Fax: 516-487-8887
Mailing address:
  • Phone: 516-487-8888
  • Fax: 516-487-8887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DWIGHT CARLTON DE RISI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 516-487-8888