Provider Demographics
NPI:1669890166
Name:THADATHIL, LINCY SIMON (DO)
Entity type:Individual
Prefix:
First Name:LINCY
Middle Name:SIMON
Last Name:THADATHIL
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 1:301 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8408
Mailing Address - Country:US
Mailing Address - Phone:631-968-3330
Mailing Address - Fax:631-968-3690
Practice Address - Street 1:301 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8408
Practice Address - Country:US
Practice Address - Phone:631-968-3330
Practice Address - Fax:631-968-3690
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR5480208100000X
390200000X
NY296701208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program