Healthcare Provider Details

I. General information

NPI: 1730228800
Provider Name (Legal Business Name): MAGERY NAGARAJA SATISH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 HOLLYWOOD DR
SMITHTOWN NY
11787-3135
US

IV. Provider business mailing address

8 ROBERT CRES
STONY BROOK NY
11790-3204
US

V. Phone/Fax

Practice location:
  • Phone: 631-366-5800
  • Fax: 631-366-2935
Mailing address:
  • Phone: 631-689-3504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberNY193882
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier01457510
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: