Provider Demographics
NPI:1306816129
Name:MORMANDO, ROBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:MORMANDO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 HALLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1232
Mailing Address - Country:US
Mailing Address - Phone:631-642-1100
Mailing Address - Fax:631-642-1190
Practice Address - Street 1:410 HALLOCK AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1232
Practice Address - Country:US
Practice Address - Phone:631-642-1100
Practice Address - Fax:631-642-1190
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200407207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY200407OtherLICENSE
NY200407OtherLICENSE
02N491Medicare ID - Type Unspecified