=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902290869
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TODD J. MALTESE, D.O., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2015
-----------------------------------------------------
Last Update Date | 03/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 HAWKINS AVE SUITE 7
-----------------------------------------------------
City | RONKONKOMA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11779-2366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-737-0055
-----------------------------------------------------
Fax | 631-737-0076
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 HAWKINS AVE SUITE 7
-----------------------------------------------------
City | RONKONKOMA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11779-2366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-737-0055
-----------------------------------------------------
Fax | 631-737-0076
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. TODD J. MALTESE
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 631-737-0055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 265409
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------