Provider Demographics
NPI:1689677197
Name:LONG ISLAND SKIN CANCER AND DERMATOLOGIC SURGERY, PC
Entity Type:Organization
Organization Name:LONG ISLAND SKIN CANCER AND DERMATOLOGIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-524-4033
Mailing Address - Street 1:994 W JERICHO TPKE
Mailing Address - Street 2:STE 103
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3211
Mailing Address - Country:US
Mailing Address - Phone:631-864-6647
Mailing Address - Fax:631-864-6001
Practice Address - Street 1:994 W JERICHO TPKE
Practice Address - Street 2:STE 103
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3211
Practice Address - Country:US
Practice Address - Phone:631-864-6647
Practice Address - Fax:631-864-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226570174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB57924Medicare UPIN
NYI24844Medicare UPIN
NY3K4531Medicare ID - Type UnspecifiedANTHONY WONG, MD'S MEDICA
NY60F111Medicare ID - Type UnspecifiedDANIEL SIEGEL, MD'S MEDIC