Healthcare Provider Details

I. General information

NPI: 1184726960
Provider Name (Legal Business Name): OLD COUNTRY PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

556 OLD COUNTRY RD
PLAINVIEW NY
11803
US

IV. Provider business mailing address

556 OLD COUNTRY RD
PLAINVIEW NY
11803
US

V. Phone/Fax

Practice location:
  • Phone: 516-938-3232
  • Fax:
Mailing address:
  • Phone: 516-938-3232
  • Fax: 516-938-8443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number181879
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name: CHARLES L BRUZZONE
Title or Position: PRESIDENT
Credential: MD
Phone: 516-938-3232