Provider Demographics
NPI:1700831195
Name:STONY BROOK OPHTHALMOLOGY, UNIVERSITY FACULTY PRACTICE CORPORATION
Entity Type:Organization
Organization Name:STONY BROOK OPHTHALMOLOGY, UNIVERSITY FACULTY PRACTICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SIBONY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-444-4092
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0988
Mailing Address - Country:US
Mailing Address - Phone:631-444-4092
Mailing Address - Fax:
Practice Address - Street 1:SUNY @ STONY BROOK
Practice Address - Street 2:HSC, L2, RM 152
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-4092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02139646Medicaid
NYW91751Medicare PIN