Healthcare Provider Details

I. General information

NPI: 1669578159
Provider Name (Legal Business Name): MARC CIMMINO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 MONTAUK HWY
OAKDALE NY
11769-1434
US

IV. Provider business mailing address

PO BOX 318
EAST ISLIP NY
11730-0318
US

V. Phone/Fax

Practice location:
  • Phone: 631-400-8400
  • Fax: 631-772-2495
Mailing address:
  • Phone: 631-969-8700
  • Fax: 631-696-8703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number172519
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number172519
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: