Healthcare Provider Details

I. General information

NPI: 1043275605
Provider Name (Legal Business Name): JOHN A IPPOLITO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S JERSEY AVE UNIT 19
SETAUKET NY
11733-2034
US

IV. Provider business mailing address

100 S JERSEY AVE
SETAUKET NY
11733-2034
US

V. Phone/Fax

Practice location:
  • Phone: 631-689-5000
  • Fax:
Mailing address:
  • Phone: 631-689-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number167286
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: