Provider Demographics
NPI:1598789760
Name:VONALTHEN-DAGUM, ISABELLE M (MD)
Entity Type:Individual
Prefix:
First Name:ISABELLE
Middle Name:M
Last Name:VONALTHEN-DAGUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-4064
Mailing Address - Country:US
Mailing Address - Phone:631-444-5220
Mailing Address - Fax:631-444-5225
Practice Address - Street 1:3 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-4064
Practice Address - Country:US
Practice Address - Phone:631-444-5220
Practice Address - Fax:631-444-5225
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231934207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02223614Medicaid
NY02223614Medicaid
NYH52253Medicare UPIN