Healthcare Provider Details

I. General information

NPI: 1184633307
Provider Name (Legal Business Name): STANFORD LEE WALKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 02/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SOUTH BROOKHAVEN HEALTH CENTER 365 EAST MAIN ST
PATCHOGUE NY
11772
US

IV. Provider business mailing address

1869 BRENTWOOD RD 365 EAST MAIN ST
BRENTWOOD NY
11717-4625
US

V. Phone/Fax

Practice location:
  • Phone: 631-854-1307
  • Fax: 631-854-1310
Mailing address:
  • Phone: 631-416-5480
  • Fax: 631-994-2900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number180556
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier01153171
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: