Healthcare Provider Details

I. General information

NPI: 1114364510
Provider Name (Legal Business Name): MILLENNIUM MEDICAL PROFESSIONALS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2013
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

496 SMITHTOWN BYP SUITE 101
SMITHTOWN NY
11787-5010
US

IV. Provider business mailing address

496 SMITHTOWN BYP SUITE 101
SMITHTOWN NY
11787-5010
US

V. Phone/Fax

Practice location:
  • Phone: 631-979-8880
  • Fax: 631-979-8064
Mailing address:
  • Phone: 631-979-8880
  • Fax: 631-979-8064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JYOTI P GANGULY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 631-979-8880