Provider Demographics
NPI:1659313617
Name:POMEROY, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:POMEROY
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-632-3785
Mailing Address - Fax:
Practice Address - Street 1:5 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1595
Practice Address - Country:US
Practice Address - Phone:631-632-3785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1468622084P0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4346743OtherAETNA
NY00743715Medicaid
NY00743715Medicaid
NY87A6691061Medicare PIN