Healthcare Provider Details

I. General information

NPI: 1295162543
Provider Name (Legal Business Name): MATHER PRIMARY CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 OAKLAND AVE SUITE 205
PORT JEFFERSON NY
11777-2130
US

IV. Provider business mailing address

125 OAKLAND AVE SUITE 205
PORT JEFFERSON NY
11777-2130
US

V. Phone/Fax

Practice location:
  • Phone: 631-686-2523
  • Fax: 631-686-2525
Mailing address:
  • Phone: 631-686-2523
  • Fax: 631-686-2525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOAN FARO
Title or Position: PRESIDENT
Credential:
Phone: 631-473-1320