Provider Demographics
NPI:1073190187
Name:MENNILLO, HARAN ASHER
Entity Type:Individual
Prefix:
First Name:HARAN
Middle Name:ASHER
Last Name:MENNILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 NICOLLS ROAD
Mailing Address - Street 2:STONY BROOK MEDICINE HSC LEVEL 11 RM 040
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794
Mailing Address - Country:US
Mailing Address - Phone:631-444-2020
Mailing Address - Fax:631-444-2894
Practice Address - Street 1:101 NICOLLS ROAD
Practice Address - Street 2:STONY BROOK MEDICINE HSC LEVEL 11 RM 040
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794
Practice Address - Country:US
Practice Address - Phone:631-444-2020
Practice Address - Fax:631-444-2894
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program