Healthcare Provider Details

I. General information

NPI: 1437227865
Provider Name (Legal Business Name): WANTAGH PEDIATRIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 JERUSALEM AVE
N BELLMORE NY
11714
US

IV. Provider business mailing address

2415 JERUSALEM AVE
N BELLMORE NY
11714
US

V. Phone/Fax

Practice location:
  • Phone: 516-221-5151
  • Fax: 516-221-0566
Mailing address:
  • Phone: 516-221-5151
  • Fax: 516-221-0566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: PETER AXEL
Title or Position: PRESIDENT
Credential: MD
Phone: 516-221-5151