Provider Demographics
NPI:1710994876
Name:GRIFFIN, DOUGLAS (PT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 SPRING HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1123
Mailing Address - Country:US
Mailing Address - Phone:631-261-3640
Mailing Address - Fax:
Practice Address - Street 1:801 MERRICK AVE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-4748
Practice Address - Country:US
Practice Address - Phone:516-393-8900
Practice Address - Fax:516-393-8869
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2228929-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQP8611Medicare PIN