Healthcare Provider Details

I. General information

NPI: 1649064593
Provider Name (Legal Business Name): CONNOR MATTINGLY SMITH RRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL RD
PATCHOGUE NY
11772-4870
US

IV. Provider business mailing address

65 MEADOWOODS LN APT 6
MORICHES NY
11955-2002
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-7100
  • Fax:
Mailing address:
  • Phone: 518-960-0209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number000269
License Number StateNY

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: