=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265257141
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN PATRICK DEMARTINO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2024
-----------------------------------------------------
Last Update Date | 11/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 499 SUNRISE HWY W STE 80
-----------------------------------------------------
City | PATCHOGUE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11772-2290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-289-2010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 VERBENA DR
-----------------------------------------------------
City | COMMACK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11725-3716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-864-6922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 011111
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------