Healthcare Provider Details

I. General information

NPI: 1548204613
Provider Name (Legal Business Name): ROBERT BOBROW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 04/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WAVERLY AVE
PATCHOGUE NY
11772-1555
US

IV. Provider business mailing address

PO BOX 1559
STONY BROOK NY
11790-0989
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-6300
  • Fax:
Mailing address:
  • Phone: 631-444-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number109079
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4373158
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerAETNA
# 2
Identifier01011123
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 3
Identifier9X4113
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerEMPIRE BC.BS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: