Healthcare Provider Details

I. General information

NPI: 1194719484
Provider Name (Legal Business Name): SUFFOLK PEDIATRIC ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MONTAUK HWY
WEST ISLIP NY
11795-4910
US

IV. Provider business mailing address

1111 MONTAUK HWY
WEST ISLIP NY
11795-4910
US

V. Phone/Fax

Practice location:
  • Phone: 631-661-2520
  • Fax: 631-669-6502
Mailing address:
  • Phone: 631-661-2520
  • Fax: 631-669-6502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: IRA P WOLETSKY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 631-661-2520