Healthcare Provider Details

I. General information

NPI: 1669479010
Provider Name (Legal Business Name): ROBERT S NISSAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 03/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 MAIN ST
NORTHPORT NY
11768-1790
US

IV. Provider business mailing address

325 MAIN ST
NORTHPORT NY
11768-1790
US

V. Phone/Fax

Practice location:
  • Phone: 631-261-4445
  • Fax: 631-261-3710
Mailing address:
  • Phone: 631-261-4445
  • Fax: 631-261-3710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number131824
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: