Healthcare Provider Details

I. General information

NPI: 1841531142
Provider Name (Legal Business Name): MD 365 MEDICAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MONTAUK HWY STE 18
SHIRLEY NY
11967-2128
US

IV. Provider business mailing address

800-18 MONTAUK HIGHWAY
SHIRLEY NY
11967-2128
US

V. Phone/Fax

Practice location:
  • Phone: 631-772-4646
  • Fax: 631-772-2495
Mailing address:
  • Phone: 631-772-4646
  • Fax: 631-772-2495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DEEPU ALEXANDER
Title or Position: M.D
Credential: MD
Phone: 631-772-4646