Provider Demographics
NPI:1730102351
Name:PATI, SUSMITA (MD)
Entity Type:Individual
Prefix:
First Name:SUSMITA
Middle Name:
Last Name:PATI
Suffix:
Gender:F
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:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-0650
Mailing Address - Fax:
Practice Address - Street 1:4 TECHNOLOGY DR
Practice Address - Street 2:SUITE 250
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-4080
Practice Address - Country:US
Practice Address - Phone:631-444-4601
Practice Address - Fax:631-444-4990
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD419905208000000X
NY210122208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8952906Medicaid
PA001914082Medicaid
H72540Medicare UPIN
PA063664Medicare ID - Type Unspecified