Provider Demographics
NPI:1336134139
Name:DOURMASHKIN, MICHAEL RALPH (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RALPH
Last Name:DOURMASHKIN
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 1:4230 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-5700
Mailing Address - Country:US
Mailing Address - Phone:516-796-2222
Mailing Address - Fax:516-796-2303
Practice Address - Street 1:532 BROADHOLLOW RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3672
Practice Address - Country:US
Practice Address - Phone:516-931-0041
Practice Address - Fax:516-822-1686
Is Sole Proprietor?:No
Enumeration Date:2005-09-17
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY151947208800000X
NJ51668208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01093425Medicaid
NY31E461Medicare ID - Type UnspecifiedNASSAU & SUFFOLK COUNTIES
NY01093425Medicaid
NJ647728Medicare ID - Type Unspecified
NYB12720Medicare UPIN