Healthcare Provider Details

I. General information

NPI: 1528254570
Provider Name (Legal Business Name): JOHN DOUGLAS BEDELL III DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2007
Last Update Date: 08/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4042 AUSTIN BLVD
ISLAND PARK NY
11558-1226
US

IV. Provider business mailing address

4042A AUSTIN BLVD
ISLAND PARK NY
11558
US

V. Phone/Fax

Practice location:
  • Phone: 516-670-8800
  • Fax: 516-670-8803
Mailing address:
  • Phone: 516-670-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number242859
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: