Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 185229 | NY |
NPI | 1619900867 |
---|---|
Provider Name | Dr. Timothy John Mosomillo |
First Address | West Babylon, NY 11704-7626 |
Second Address | West Babylon, NY 11704-7626 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F93707 | (02) |