=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730432303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARCUS ABBOUD DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2012
-----------------------------------------------------
Last Update Date | 10/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1104 WESTCHESTER HL
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11794-8706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-632-9371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 CLUB HOUSE CT
-----------------------------------------------------
City | SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733-1041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-388-2372
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 000032
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------