Healthcare Provider Details

I. General information

NPI: 1790247005
Provider Name (Legal Business Name): MARIAM ATIA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 ROANOKE AVE
RIVERHEAD NY
11901-2058
US

IV. Provider business mailing address

289 WESTWOOD AVE APT 5C
STATEN ISLAND NY
10314-5426
US

V. Phone/Fax

Practice location:
  • Phone: 631-727-1600
  • Fax:
Mailing address:
  • Phone: 646-620-3416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number314011
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number314011
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: