Provider Demographics
NPI:1295944981
Name:SURPRIS, MARIE GRAZIELLA (DO)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:GRAZIELLA
Last Name:SURPRIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 NICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-2115
Mailing Address - Country:US
Mailing Address - Phone:631-467-0867
Mailing Address - Fax:631-467-0892
Practice Address - Street 1:148 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-2115
Practice Address - Country:US
Practice Address - Phone:631-467-0867
Practice Address - Fax:631-467-0892
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21574812084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry