Healthcare Provider Details

I. General information

NPI: 1548288590
Provider Name (Legal Business Name): WAJDY LOUIS HAILOO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 RONKONKOMA AVE
RONKONKOMA NY
11779-3346
US

IV. Provider business mailing address

210 RONKONKOMA AVE
RONKONKOMA NY
11779-3346
US

V. Phone/Fax

Practice location:
  • Phone: 631-780-6611
  • Fax: 631-780-6624
Mailing address:
  • Phone: 631-780-6611
  • Fax: 631-780-6624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number169252
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: