Provider Demographics
NPI:1417905696
Name:PERRONE, ROGER (MD)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:PERRONE
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 1:1019 FORT SALONGA RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2270
Mailing Address - Country:US
Mailing Address - Phone:631-262-1314
Mailing Address - Fax:631-262-1328
Practice Address - Street 1:1019 FORT SALONGA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2270
Practice Address - Country:US
Practice Address - Phone:631-262-1314
Practice Address - Fax:631-262-1328
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175975207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01197777Medicaid
NYW34601OtherGROUP UPIN
NYE48930Medicare UPIN
NY56F931Medicare ID - Type Unspecified