Provider Demographics
NPI:1619075512
Name:BRATHWAITE, COLLIN E M (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLIN
Middle Name:E M
Last Name:BRATHWAITE
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 1:120 MINEOLA BLVD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4073
Mailing Address - Country:US
Mailing Address - Phone:516-663-3300
Mailing Address - Fax:516-663-2136
Practice Address - Street 1:120 MINEOLA BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4073
Practice Address - Country:US
Practice Address - Phone:516-663-3300
Practice Address - Fax:516-663-2136
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211561174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01875290Medicaid
NY0199636OtherGHI
NYN90256OtherHEALTHNET
NYP3072342OtherOXFORD FREEDOM PLAN
NY158053OtherVYTRA
NYAA72078OtherMDNY
NY23R982OtherEMPIRE BC BS
NY5856167OtherAETNA
NY5808725008OtherCIGNA
NY23R982OtherEMPIRE BC BS
NY5808725008OtherCIGNA