Provider Demographics
NPI:1417057308
Name:SCARBROUGH, KATHLEEN HARRIS (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:HARRIS
Last Name:SCARBROUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:16 GABRIEL MILLS RD STE 3
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-1506
Mailing Address - Country:US
Mailing Address - Phone:631-655-2516
Mailing Address - Fax:
Practice Address - Street 1:181 N BELLE MEAD RD STE 2
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3495
Practice Address - Country:US
Practice Address - Phone:631-444-6250
Practice Address - Fax:631-444-6665
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244603-1207VG0400X
NY2446032083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001407974Medicaid
160002069Medicare ID - Type Unspecified
CT001407974Medicaid