Provider Demographics
NPI:1770679557
Name:MONTELLESE, DANIEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:R
Last Name:MONTELLESE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1320 STONY BROOK ROAD
Mailing Address - Street 2:BLDG D, SUITE 100
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790
Mailing Address - Country:US
Mailing Address - Phone:631-941-2273
Mailing Address - Fax:631-941-2501
Practice Address - Street 1:1320 STONY BROOK RD STE 100
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790
Practice Address - Country:US
Practice Address - Phone:631-941-2273
Practice Address - Fax:631-941-2501
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241554207R00000X, 207RI0011X
NY241554-1207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03427332Medicaid
NYA40085718Medicare UPIN
A400012242Medicare PIN