Healthcare Provider Details

I. General information

NPI: 1619934205
Provider Name (Legal Business Name): KEITH G ANCONA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E MAIN ST SUITE 5
SMITHTOWN NY
11787-2900
US

IV. Provider business mailing address

300 E MAIN ST SUITE 5
SMITHTOWN NY
11787-2900
US

V. Phone/Fax

Practice location:
  • Phone: 631-979-6466
  • Fax: 631-979-6475
Mailing address:
  • Phone: 631-979-6466
  • Fax: 631-979-6475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number221658
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02413734
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: