Healthcare Provider Details

I. General information

NPI: 1174556963
Provider Name (Legal Business Name): ISLAND GASTROENTEROLOGY CONSULTANTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MONTAUK HWY 3RD FLOOR
WEST ISLIP NY
11795-4910
US

IV. Provider business mailing address

1111 MONTAUK HWY 3RD FLOOR
WEST ISLIP NY
11795-4910
US

V. Phone/Fax

Practice location:
  • Phone: 631-669-1171
  • Fax: 631-669-1912
Mailing address:
  • Phone: 631-669-1171
  • Fax: 631-669-1912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number143127
License Number StateNY

VIII. Authorized Official

Name: DR. RAJ MARIWALLA
Title or Position: GASTROENTEROLOGIST
Credential: MD
Phone: 631-669-1171