Provider Demographics
NPI:1588001317
Name:CLOSSON, WILLIAM JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JOHN
Last Name:CLOSSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 JAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2836
Mailing Address - Country:US
Mailing Address - Phone:516-527-2153
Mailing Address - Fax:631-337-4094
Practice Address - Street 1:179 JAYNE AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2836
Practice Address - Country:US
Practice Address - Phone:516-527-2153
Practice Address - Fax:631-337-4094
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCLOSW1247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01424097Medicaid