Provider Demographics
NPI:1902892581
Name:GILLERAN, STEPHANIE N (DO)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:N
Last Name:GILLERAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 SILLS RD
Mailing Address - Street 2:BUILDING 7, SUITE B
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4869
Mailing Address - Country:US
Mailing Address - Phone:631-654-4577
Mailing Address - Fax:631-654-3391
Practice Address - Street 1:285 SILLS RD
Practice Address - Street 2:BUILDING 7, SUITE B
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4869
Practice Address - Country:US
Practice Address - Phone:631-654-4577
Practice Address - Fax:631-654-3391
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221807207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02556187Medicaid
I20995Medicare UPIN
049751Medicare ID - Type Unspecified