Provider Demographics
NPI:1255386959
Name:SPADAFORA, PHILIP FORTUNATO (DO)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:FORTUNATO
Last Name:SPADAFORA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 STEWART AVE
Mailing Address - Street 2:STE 275
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530
Mailing Address - Country:US
Mailing Address - Phone:516-877-1518
Mailing Address - Fax:516-877-1561
Practice Address - Street 1:901 STEWART AVE
Practice Address - Street 2:STE 275
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530
Practice Address - Country:US
Practice Address - Phone:516-877-1518
Practice Address - Fax:516-877-1561
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1878871207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
26J671Medicare ID - Type Unspecified
F85168Medicare UPIN