Provider Demographics
NPI:1275576787
Name:DE SAGUN, LYONEL
Entity Type:Individual
Prefix:
First Name:LYONEL
Middle Name:
Last Name:DE SAGUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LYONEL
Other - Middle Name:
Other - Last Name:DE SAGUN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:10 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-2911
Mailing Address - Country:US
Mailing Address - Phone:631-816-9696
Mailing Address - Fax:
Practice Address - Street 1:1979 MARCUS AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042-1002
Practice Address - Country:US
Practice Address - Phone:516-327-4681
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019091225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY019091OtherPT LICENSE