Provider Demographics
NPI:1881637700
Name:DECRISTOFARO, JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:DECRISTOFARO
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: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 1:100 NICOLLS RD
Practice Address - Street 2:STONY BROOK HOSPITAL
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8111
Practice Address - Country:US
Practice Address - Phone:631-444-7653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1566362080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY22F41OtherEMPIRE BC.BS
NYE17646Medicare UPIN
NYA400039424Medicare PIN
NY4219813OtherAETNA
NY01132434Medicaid