Provider Demographics
NPI:1619962966
Name:CHRISPHONTE, MARTIN AJAX (MD)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:AJAX
Last Name:CHRISPHONTE
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 1:750 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-3642
Mailing Address - Country:US
Mailing Address - Phone:631-249-2765
Mailing Address - Fax:631-249-3617
Practice Address - Street 1:750 FULTON ST
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3642
Practice Address - Country:US
Practice Address - Phone:631-249-2765
Practice Address - Fax:631-249-3617
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1902942084P0805X, 2084P0800X
FLME858712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01810975Medicaid
56J611Medicare ID - Type Unspecified
NY01810975Medicaid