Healthcare Provider Details

I. General information

NPI: 1558660456
Provider Name (Legal Business Name): ERIK KOCKENMEISTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BEACH DR FL 2
WEST ISLIP NY
11795-4929
US

IV. Provider business mailing address

111 BEACH DR FL 2
WEST ISLIP NY
11795-4929
US

V. Phone/Fax

Practice location:
  • Phone: 631-417-8600
  • Fax:
Mailing address:
  • Phone: 631-417-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number268005
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: