Healthcare Provider Details

I. General information

NPI: 1386682565
Provider Name (Legal Business Name): ROGELIO S LAO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 COMMERCE AVE SUITE 2
RIVERHEAD NY
11901-3118
US

IV. Provider business mailing address

68 S SERVICE RD SUITE 350
MELVILLE NY
11747-2354
US

V. Phone/Fax

Practice location:
  • Phone: 631-722-8880
  • Fax: 631-722-7851
Mailing address:
  • Phone: 516-945-3000
  • Fax: 516-945-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number103078
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: