Provider Demographics
NPI:1659493575
Name:CELESTINO, PHILIP JOSEPH (CPED)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:JOSEPH
Last Name:CELESTINO
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1843
Mailing Address - Country:US
Mailing Address - Phone:631-476-9717
Mailing Address - Fax:631-476-9718
Practice Address - Street 1:403 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1843
Practice Address - Country:US
Practice Address - Phone:631-476-9717
Practice Address - Fax:631-476-9718
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1823174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4983710001Medicare ID - Type UnspecifiedPROVIDER NUMBER