Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | X004289-1 | NY |
NPI | 1508815804 |
---|---|
Provider Name | Dr. Robert J Melillo |
First Address | Ronkonkoma, NY 11779-7647 |
Second Address | Ronkonkoma, NY 11779-7647 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T99877 | (02) | NY |
X08911 | EMPIRE BCBS (01) | NY |