Provider Demographics
NPI:1093886509
Name:O'SHAUGHNESSY, ALICE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:MARIE
Last Name:O'SHAUGHNESSY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747-20 NESCONSET HWY
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776
Mailing Address - Country:US
Mailing Address - Phone:631-474-5500
Mailing Address - Fax:631-474-2568
Practice Address - Street 1:4747-20 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2894
Practice Address - Country:US
Practice Address - Phone:631-474-5500
Practice Address - Fax:631-474-2568
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY107072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00765540Medicaid
NY280901Medicare ID - Type Unspecified
NYC07754Medicare UPIN