Healthcare Provider Details

I. General information

NPI: 1477629400
Provider Name (Legal Business Name): MANTIA MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

496 NESCONSET HIGHWAY STE 200
SMITHTOWN NY
11787
US

IV. Provider business mailing address

496 NESCONSET HIGHWAY STE 200
SMITHTOWN NY
11787
US

V. Phone/Fax

Practice location:
  • Phone: 631-265-9111
  • Fax:
Mailing address:
  • Phone: 631-265-9111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number182606
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number094617
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number124142
License Number StateNY

VIII. Authorized Official

Name: AUGUSTUS MANTIA
Title or Position: MD
Credential:
Phone: 631-265-9111