Provider Demographics
NPI:1619900867
Name:MOSOMILLO, TIMOTHY JOHN (DO, NMM)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:MOSOMILLO
Suffix:
Gender:M
Credentials:DO, NMM
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:426 GREAT EAST NECK RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-7626
Mailing Address - Country:US
Mailing Address - Phone:631-661-6611
Mailing Address - Fax:631-661-5504
Practice Address - Street 1:426 GREAT EAST NECK RD
Practice Address - Street 2:SUITE C
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-7626
Practice Address - Country:US
Practice Address - Phone:631-661-6611
Practice Address - Fax:631-661-5504
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185229204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
W86941Medicare ID - Type Unspecified
F93707Medicare UPIN