Provider Demographics
NPI:1568450187
Name:CAPULONG, ERNESTO (MD)
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:CAPULONG
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 1:1 HEALTHY WAY
Mailing Address - Street 2:ATTN: PHYSICIAN BILLING DEPT
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1551
Mailing Address - Country:US
Mailing Address - Phone:516-255-8200
Mailing Address - Fax:
Practice Address - Street 1:440 MERRICK RD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1404
Practice Address - Country:US
Practice Address - Phone:516-255-8200
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124998208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00841378Medicaid
NY357361Medicare ID - Type Unspecified
NY00841378Medicaid