Provider Demographics
NPI:1578934964
Name:WERTHEIM, MARY (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WERTHEIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 SETALCOTT PL
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1323
Mailing Address - Country:US
Mailing Address - Phone:631-624-6857
Mailing Address - Fax:
Practice Address - Street 1:STONY BROOK MEDICINE EM
Practice Address - Street 2:100 NICOLLS ROAD, HSC, LEVEL 4, ROOM 080
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8350
Practice Address - Country:US
Practice Address - Phone:631-444-2478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307318-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health