Healthcare Provider Details

I. General information

NPI: 1265420764
Provider Name (Legal Business Name): STEVEN J LEDERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 ROANOKE AVE
RIVERHEAD NY
11901-2724
US

IV. Provider business mailing address

951 ROANOKE AVE
RIVERHEAD NY
11901-2724
US

V. Phone/Fax

Practice location:
  • Phone: 631-727-7773
  • Fax: 631-369-4994
Mailing address:
  • Phone: 631-369-5005
  • Fax: 631-369-4994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number194055
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: