Healthcare Provider Details

I. General information

NPI: 1316957707
Provider Name (Legal Business Name): JOANNE M. KECHEJIAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 10/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 SOUTHERN BLVD
NESCONSET NY
11767-1090
US

IV. Provider business mailing address

59 SOUTHERN BLVD
NESCONSET NY
11767-1090
US

V. Phone/Fax

Practice location:
  • Phone: 631-659-1700
  • Fax: 631-659-1750
Mailing address:
  • Phone: 631-659-1700
  • Fax: 631-659-1750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number197006-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: