Healthcare Provider Details

I. General information

NPI: 1477256758
Provider Name (Legal Business Name): IAN BLAIKIE MATHIES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NICOLLS ROAD HSC LEVEL 4 ROOM 050
STONY BROOK NY
11794
US

IV. Provider business mailing address

60 WOODSOME RD
BABYLON NY
11702-3318
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-3880
  • Fax: 631-444-3919
Mailing address:
  • Phone: 631-943-9051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number346732
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: