Provider Demographics
NPI:1205168739
Name:NICK H GABRIEL DO PC
Entity type:Organization
Organization Name:NICK H GABRIEL DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:H
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-862-3801
Mailing Address - Street 1:48 ROUTE 25A
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1431
Mailing Address - Country:US
Mailing Address - Phone:631-862-3801
Mailing Address - Fax:631-862-3068
Practice Address - Street 1:48 ROUTE 25A
Practice Address - Street 2:SUITE 104
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1431
Practice Address - Country:US
Practice Address - Phone:631-862-3801
Practice Address - Fax:631-862-3068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200259208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02126956Medicaid
H22244Medicare UPIN