Provider Demographics
NPI:1760507552
Name:WILL, MICHAEL VINCENT (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:VINCENT
Last Name:WILL
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 1:17 WANTAGH AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730
Mailing Address - Country:US
Mailing Address - Phone:631-277-3868
Mailing Address - Fax:631-859-0154
Practice Address - Street 1:55 CARLETON AVE
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730
Practice Address - Country:US
Practice Address - Phone:631-859-0994
Practice Address - Fax:631-859-0154
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17894812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01617514Medicaid
30I201Medicare ID - Type Unspecified
NY01617514Medicaid