Provider Demographics
NPI:1538114707
Name:STONY BROOK UROLOGY, UNIVERSITY FACULTY PRACTICE CORPORATION
Entity Type:Organization
Organization Name:STONY BROOK UROLOGY, UNIVERSITY FACULTY PRACTICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR PERSON
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTZER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-444-1252
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0988
Mailing Address - Country:US
Mailing Address - Phone:631-444-1252
Mailing Address - Fax:
Practice Address - Street 1:24 RESEARCH WAY
Practice Address - Street 2:SUITE 500
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3487
Practice Address - Country:US
Practice Address - Phone:631-444-6270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00778890Medicaid
NY0973460001Medicare NSC
NYW91621Medicare PIN