Provider Demographics
NPI:1275657793
Name:SAINT LAURENT, MARIO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:SAINT LAURENT
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 1:10 SUGAR MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-6248
Mailing Address - Country:US
Mailing Address - Phone:631-243-1423
Mailing Address - Fax:631-940-0552
Practice Address - Street 1:3765 104TH ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-1947
Practice Address - Country:US
Practice Address - Phone:718-507-5656
Practice Address - Fax:718-507-0884
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155418208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics