Healthcare Provider Details

I. General information

NPI: 1497940019
Provider Name (Legal Business Name): LONG ISLAND VITREO RETINAL CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 COMMERCE DR SUITE 2
RIVERHEAD NY
11901-3106
US

IV. Provider business mailing address

47 COMMERCE DR SUITE 2
RIVERHEAD NY
11901-3106
US

V. Phone/Fax

Practice location:
  • Phone: 631-905-0666
  • Fax: 516-905-0660
Mailing address:
  • Phone: 631-905-0666
  • Fax: 516-905-0660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: ANNMARIE GAMBA
Title or Position: BILLING MANAGER
Credential:
Phone: 516-466-0390