Provider Demographics
NPI:1750300844
Name:ISSACOFF, CLIFFORD (PH D)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:
Last Name:ISSACOFF
Suffix:
Gender:M
Credentials:PH D
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 254
Mailing Address - Street 2:
Mailing Address - City:ISLIP TERRACE
Mailing Address - State:NY
Mailing Address - Zip Code:11752-0254
Mailing Address - Country:US
Mailing Address - Phone:631-277-8367
Mailing Address - Fax:631-277-3140
Practice Address - Street 1:126 E MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2600
Practice Address - Country:US
Practice Address - Phone:631-277-8367
Practice Address - Fax:631-277-3140
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009286103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VM1301Medicare PIN