Provider Demographics
NPI:1477578086
Name:LYNCH, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:LYNCH
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 1:375 E MAIN ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8418
Mailing Address - Country:US
Mailing Address - Phone:631-666-5620
Mailing Address - Fax:631-666-4668
Practice Address - Street 1:375 E MAIN ST
Practice Address - Street 2:SUITE 12
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8418
Practice Address - Country:US
Practice Address - Phone:631-666-5620
Practice Address - Fax:631-666-4668
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1201382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY258131Medicaid
NY258131Medicaid
NYB80444Medicare UPIN