Provider Demographics
NPI:1508874462
Name:JOHANIDESZ, GEZA (MD)
Entity Type:Individual
Prefix:
First Name:GEZA
Middle Name:
Last Name:JOHANIDESZ
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 1:299 RONKONKOMA AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779
Mailing Address - Country:US
Mailing Address - Phone:631-588-7007
Mailing Address - Fax:631-588-1022
Practice Address - Street 1:299 RONKONKOMA AVE
Practice Address - Street 2:UNIT A
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779
Practice Address - Country:US
Practice Address - Phone:631-588-7007
Practice Address - Fax:631-588-1022
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170805207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A60307Medicare UPIN
07E701Medicare ID - Type Unspecified