Healthcare Provider Details

I. General information

NPI: 1205323359
Provider Name (Legal Business Name): AMAR VYAS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2018
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 MONTAUK HWY STE A
SHIRLEY NY
11967-2153
US

IV. Provider business mailing address

1300 ROANOKE AVE
RIVERHEAD NY
11901-2031
US

V. Phone/Fax

Practice location:
  • Phone: 631-369-5000
  • Fax:
Mailing address:
  • Phone: 631-639-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number309430
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: