Provider Demographics
NPI:1568657575
Name:ST TEREIZA OFF OF PHY TER PC
Entity Type:Organization
Organization Name:ST TEREIZA OFF OF PHY TER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:DR
Authorized Official - First Name:MALAK
Authorized Official - Middle Name:ISHAK
Authorized Official - Last Name:AZAB
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:631-467-3381
Mailing Address - Street 1:16 DEER LN
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3407
Mailing Address - Country:US
Mailing Address - Phone:631-467-3381
Mailing Address - Fax:631-467-3383
Practice Address - Street 1:1787 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3507
Practice Address - Country:US
Practice Address - Phone:631-467-3381
Practice Address - Fax:631-467-3383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021295174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4W2J1Medicare PIN
NY6238530001Medicare NSC