Provider Demographics
NPI:1619991734
Name:LANDOLPHI, DANIEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:R
Last Name:LANDOLPHI
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 1:1920 DEER PARK AVE
Mailing Address - Street 2:SUITE104
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-3314
Mailing Address - Country:US
Mailing Address - Phone:631-392-1680
Mailing Address - Fax:631-392-1683
Practice Address - Street 1:1920 DEER PARK AVE
Practice Address - Street 2:SUITE104
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-3314
Practice Address - Country:US
Practice Address - Phone:631-392-1680
Practice Address - Fax:631-392-1683
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186182207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400009510Medicare PIN
NYG20906Medicare UPIN