Provider Demographics
NPI:1396067591
Name:ANTHONY N. DONATELLI JR MD., PC
Entity type:Organization
Organization Name:ANTHONY N. DONATELLI JR MD., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:N
Authorized Official - Last Name:DONATELLI
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD,PC
Authorized Official - Phone:631-730-0406
Mailing Address - Street 1:PO BOX 406
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-0406
Mailing Address - Country:US
Mailing Address - Phone:631-730-0406
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-8809
Practice Address - Country:US
Practice Address - Phone:631-730-0406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY167827207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY167827OtherLICENSE