Provider Demographics
NPI:1568571081
Name:STAVOLA, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:STAVOLA
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 1:45 RESEARCH WAY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-6401
Mailing Address - Country:US
Mailing Address - Phone:631-941-2704
Mailing Address - Fax:631-350-7200
Practice Address - Street 1:45 RESEARCH WAY
Practice Address - Street 2:SUITE 008 & 108
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-6401
Practice Address - Country:US
Practice Address - Phone:631-941-2704
Practice Address - Fax:631-941-2009
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178562-1207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYO1416908Medicaid
NY03H011Medicare PIN
NYF66384Medicare UPIN
NYO1416908Medicaid