Provider Demographics
NPI:1669578159
Name:CIMMINO, MARC (DO)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:CIMMINO
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:PO BOX 318
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-0318
Mailing Address - Country:US
Mailing Address - Phone:631-969-8700
Mailing Address - Fax:631-696-8703
Practice Address - Street 1:971 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1434
Practice Address - Country:US
Practice Address - Phone:631-400-8400
Practice Address - Fax:631-772-2495
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172519207Q00000X, 204C00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY20F361Medicare ID - Type Unspecified
NYE17199Medicare UPIN