Healthcare Provider Details

I. General information

NPI: 1144246885
Provider Name (Legal Business Name): PHYLLIS MIGDAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NESCONSET HWY BLDG. 3C
STONY BROOK NY
11790-2555
US

IV. Provider business mailing address

2500 NESCONSET HWY BLDG. 3C
STONY BROOK NY
11790-2555
US

V. Phone/Fax

Practice location:
  • Phone: 631-751-2400
  • Fax: 631-751-8323
Mailing address:
  • Phone: 631-751-2400
  • Fax: 631-751-8323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number1965621
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: