Provider Demographics
NPI:1093801474
Name:O'LEARY, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:O'LEARY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 AMY DR
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-3224
Mailing Address - Country:US
Mailing Address - Phone:631-319-6107
Mailing Address - Fax:631-319-6110
Practice Address - Street 1:196 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-2582
Practice Address - Country:US
Practice Address - Phone:631-319-6107
Practice Address - Fax:631-319-6110
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190926207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01816751Medicaid
NY01816751Medicaid
NY01816751Medicaid