Healthcare Provider Details

I. General information

NPI: 1356339139
Provider Name (Legal Business Name): ANIL MATTOO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 SILLS ROAD BLDG. 7, SUITE B
PATCHOGUE NY
11772
US

IV. Provider business mailing address

285 SILLS ROAD BLDG. 7, SUITE B
PATCHOGUE NY
11772
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-4577
  • Fax: 631-654-3391
Mailing address:
  • Phone: 631-654-4577
  • Fax: 631-654-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number003037
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number10638
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number258417
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number003037
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number10638
License Number StateNV
# 6
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number258417
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number10638
License Number StateNV

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: