Provider Demographics
NPI:1497937056
Name:SCOTTODIMASO, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SCOTTODIMASO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-2928
Mailing Address - Country:US
Mailing Address - Phone:631-669-0333
Mailing Address - Fax:631-669-2436
Practice Address - Street 1:51 JOHN ST STE 3
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-2928
Practice Address - Country:US
Practice Address - Phone:631-669-0333
Practice Address - Fax:631-669-2436
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012945174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ59802Medicare Oscar/Certification