Healthcare Provider Details

I. General information

NPI: 1013317775
Provider Name (Legal Business Name): ANTHONY VULTAGGIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2014
Last Update Date: 09/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 AIR PARK DR
RONKONKOMA NY
11779-7360
US

IV. Provider business mailing address

14 FORREST AVE
CENTEREACH NY
11720-3639
US

V. Phone/Fax

Practice location:
  • Phone: 631-580-4020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number833098141
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: