Healthcare Provider Details

I. General information

NPI: 1447248034
Provider Name (Legal Business Name): ROBERT P WORONIECKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2005
Last Update Date: 07/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NICOLLS RD # LEVEL11
STONY BROOK NY
11794-8111
US

IV. Provider business mailing address

25 GILCHREST RD
GREAT NECK NY
11021-1404
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-7884
  • Fax:
Mailing address:
  • Phone: 516-466-0476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number205912
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: