Healthcare Provider Details

I. General information

NPI: 1184314486
Provider Name (Legal Business Name): DANIELLE MEDIATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 E PULASKI RD
HUNTINGTN STA NY
11746-1915
US

IV. Provider business mailing address

170 BROOKSITE DR
SMITHTOWN NY
11787-4404
US

V. Phone/Fax

Practice location:
  • Phone: 631-425-2110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number297671
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: