Healthcare Provider Details

I. General information

NPI: 1003825225
Provider Name (Legal Business Name): LAWRENCE JOSEPH MINEI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 EAST MAIN ST SOUTH BROOK HAVEN HEALTH CENTER WEST
PATCHOQUE NY
11772
US

IV. Provider business mailing address

365 EAST MAIN ST SOUTH BROOK HAVEN HEALTH CENTER WEST
PATCHOQUE NY
11772
US

V. Phone/Fax

Practice location:
  • Phone: 631-854-1307
  • Fax: 631-854-1310
Mailing address:
  • Phone: 631-854-1307
  • Fax: 631-854-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number105616
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: