Provider Demographics
NPI:1477512655
Name:PHILLIP, DENNIS-ROGER (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS-ROGER
Middle Name:
Last Name:PHILLIP
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:PO BOX 33682
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150-3682
Mailing Address - Country:US
Mailing Address - Phone:631-547-6392
Mailing Address - Fax:
Practice Address - Street 1:270 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2787
Practice Address - Country:US
Practice Address - Phone:631-547-6392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232970208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02581877Medicaid
NY3453H1Medicare ID - Type Unspecified
NY02581877Medicaid