Provider Demographics
NPI:1912961624
Name:IMBRIANO, LOUIS J (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:J
Last Name:IMBRIANO
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 1:200 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 135
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4235
Mailing Address - Country:US
Mailing Address - Phone:516-663-2169
Mailing Address - Fax:516-663-4619
Practice Address - Street 1:200 OLD COUNTRY RD
Practice Address - Street 2:SUITE 135
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4235
Practice Address - Country:US
Practice Address - Phone:516-663-2169
Practice Address - Fax:516-663-4619
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121548174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00751395Medicaid
NY10478803OtherCAQH
NYAI6798461OtherDEA
NY10478803OtherCAQH
NY804231Medicare ID - Type Unspecified