Provider Demographics
NPI:1215221858
Name:PELOSI, ANTHONY A (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:A
Last Name:PELOSI
Suffix:
Gender:M
Credentials:MD
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22 KNOX AVE
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-1538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 4TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7908
Practice Address - Country:US
Practice Address - Phone:631-665-6707
Practice Address - Fax:631-665-3564
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY104072-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY104072-1OtherLICENSURE