Provider Demographics
NPI:1689640690
Name:FORLETTI, DAMIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAMIAN
Middle Name:
Last Name:FORLETTI
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
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 HALLOCK AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1244
Practice Address - Country:US
Practice Address - Phone:631-331-7267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164113208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY877643OtherAETNA HMO ID
NYOC9245OtherPHS / HEALTH NET
NY164113OtherHIP
NYCP103OtherOXFORD ID
NY2787OtherVYTRA ID
NY4061141OtherAETNA NON-HMO ID
NY2600579OtherGHI PPO ID
NY1807144003OtherCIGNA ID
NY5B780OtherEMPIRE BC/BS
NY000000059056OtherGHI HMO ID
NY01082773Medicaid
NYO85640OtherUNITED HEALTH CARE
NYA62110Medicare UPIN
NY01082773Medicaid