Provider Demographics
NPI:1881872042
Name:SPEREGON, STEPHEN M
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:SPEREGON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:440 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2254
Practice Address - Country:US
Practice Address - Phone:631-758-8292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-09
Last Update Date:2008-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027977183500000X
NY02407849183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY027977Other02407849 MEDICAID