Provider Demographics
NPI:1932212354
Name:CAVALLO, JOSEPH K (MD)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:K
Last Name:CAVALLO
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 1:1500 ROUTE 112
Mailing Address - Street 2:BLDG 6
Mailing Address - City:PORT JEFF STA
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8054
Mailing Address - Country:US
Mailing Address - Phone:631-732-9090
Mailing Address - Fax:631-732-8235
Practice Address - Street 1:1500 ROUTE 112 BLDG 6
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-8054
Practice Address - Country:US
Practice Address - Phone:631-732-9090
Practice Address - Fax:631-732-8235
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158971207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2K7671Medicare ID - Type Unspecified
A65075Medicare UPIN
NYW39421Medicare PIN
NYW39422Medicare PIN