Healthcare Provider Details

I. General information

NPI: 1336187889
Provider Name (Legal Business Name): ANDREW R BONTEMPO OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 E MAIN ST
RIVERHEAD NY
11901-1524
US

IV. Provider business mailing address

1333 E MAIN ST
RIVERHEAD NY
11901-1524
US

V. Phone/Fax

Practice location:
  • Phone: 631-369-0777
  • Fax: 631-369-0976
Mailing address:
  • Phone: 631-369-0777
  • Fax: 631-369-0976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV005838
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: