=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235151572
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA JOAN IANNOTTI M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2006
-----------------------------------------------------
Last Update Date | 12/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 E MAIN ST STE 102
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-2844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-360-2200
-----------------------------------------------------
Fax | 631-360-1328
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 48 ROUTE 25A SUITE 106
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-1431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-863-1007
-----------------------------------------------------
Fax | 631-862-3668
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 222190-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------