Provider Demographics
NPI:1619091956
Name:PLAZA MEDICAL & DIAGNOSTIC, P.C.
Entity Type:Organization
Organization Name:PLAZA MEDICAL & DIAGNOSTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOMBARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-385-0207
Mailing Address - Street 1:752 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3900
Mailing Address - Country:US
Mailing Address - Phone:631-385-0207
Mailing Address - Fax:631-385-1272
Practice Address - Street 1:752 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3900
Practice Address - Country:US
Practice Address - Phone:631-385-0207
Practice Address - Fax:631-385-1272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108320207Q00000X, 207QA0401X, 207QG0300X
NY233446207Q00000X
NY224877207Q00000X
NY155061208100000X, 2081P2900X
NY097663208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW2L941Medicare ID - Type UnspecifiedGROUP NUMBER