Provider Demographics
NPI:1639160088
Name:DICLEMENTE, MICHAEL J (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:DICLEMENTE
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 1:5036 JERICHO TPKE STE 205
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-2812
Mailing Address - Country:US
Mailing Address - Phone:516-417-3488
Mailing Address - Fax:516-584-6717
Practice Address - Street 1:7 W 51ST ST FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-6910
Practice Address - Country:US
Practice Address - Phone:516-532-8149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6357207V00000X
DEC1-0024788207V00000X
NY330169207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158824-01Medicaid
TXH84032Medicare UPIN
TX8A7079Medicare ID - Type Unspecified