Provider Demographics
NPI:1093894446
Name:DORVAL-DORCELY, MARIE-JOSE (MD)
Entity Type:Individual
Prefix:
First Name:MARIE-JOSE
Middle Name:
Last Name:DORVAL-DORCELY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIE-JOSE
Other - Middle Name:
Other - Last Name:DORVAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:300 CENTER DR
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-3393
Mailing Address - Country:US
Mailing Address - Phone:631-852-1800
Mailing Address - Fax:631-852-1807
Practice Address - Street 1:300 CENTER DR
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-3393
Practice Address - Country:US
Practice Address - Phone:631-852-1800
Practice Address - Fax:631-852-1807
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215921207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02139031Medicaid
NYH28342Medicare UPIN
NY861971Medicare ID - Type Unspecified