Healthcare Provider Details

I. General information

NPI: 1568520708
Provider Name (Legal Business Name): STEPHEN GOLUB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 NORTH COUNTRY ROAD
PORT JEFFERSON NY
11777
US

IV. Provider business mailing address

118 NORTH COUNTRY ROAD
PORT JEFFERSON NY
11777
US

V. Phone/Fax

Practice location:
  • Phone: 631-473-7171
  • Fax: 631-473-4605
Mailing address:
  • Phone: 631-473-7171
  • Fax: 631-473-4605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number142187
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number1421871
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: