Healthcare Provider Details

I. General information

NPI: 1427316348
Provider Name (Legal Business Name): JEREMY MICHAEL HUGH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2012
Last Update Date: 07/05/2022
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 STONY BROOK RD
STONY BROOK NY
11790-2206
US

IV. Provider business mailing address

1320 STONY BROOK RD
STONY BROOK NY
11790-2206
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-4200
  • Fax: 631-638-4220
Mailing address:
  • Phone: 631-444-4200
  • Fax: 631-638-4220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number17511
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberDR.00588444
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number314161
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: