Provider Demographics
NPI:1962830851
Name:ROXANNE G CARFORA, DO, PC
Entity Type:Organization
Organization Name:ROXANNE G CARFORA, DO, PC
Other - Org Name:AGELESS 360 MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:G
Authorized Official - Last Name:CARFORA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-265-9355
Mailing Address - Street 1:694 MOTOR PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-5175
Mailing Address - Country:US
Mailing Address - Phone:631-265-9355
Mailing Address - Fax:631-864-8504
Practice Address - Street 1:694 MOTOR PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-5175
Practice Address - Country:US
Practice Address - Phone:631-265-9355
Practice Address - Fax:631-864-8504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-31
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186098207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY69H951Medicare PIN