Provider Demographics
NPI:1407852940
Name:PRENTISS, DAVID NEILD (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:NEILD
Last Name:PRENTISS
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 1:1300 ROANOKE AVE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2031
Mailing Address - Country:US
Mailing Address - Phone:631-548-6440
Mailing Address - Fax:631-727-0772
Practice Address - Street 1:47 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-8846
Practice Address - Country:US
Practice Address - Phone:631-821-5900
Practice Address - Fax:631-821-5906
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2019-04-03
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
NY202762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01937113Medicaid
NY01937113Medicaid