Basic Information
| Provider Information | |||||||||
| NPI: | 1124114491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAMOUR | ||||||||
| FirstName: | YVON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 272 | ||||||||
| Address2: | |||||||||
| City: | EAST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117300272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312241878 | ||||||||
| FaxNumber: | 6312247963 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 BELLE TERRE RD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117771928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314746000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 189488-1 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 189488 | 01 | NY | HIP HEALTHCARE | OTHER | 2121564 | 01 | NY | VYTRA HEALTH PLANS | OTHER | 4C9011 | 01 | NY | HEALTHNET | OTHER | 5821360 | 01 | NY | AETNA HEALTH PLANS | OTHER | ON25343 | 01 | NY | MDNY | OTHER | P3555368 | 01 | NY | OXFORD HEALTH PLANS | OTHER | YD0638Y82 | 01 | NY | EMPIRE BC/BS | OTHER | 01654948 | 05 | NY | MEDICAID | 2695524 | 01 | NY | GHI | OTHER | 1000054073 | 01 | NY | AFFINITY HEALTH PLANS | OTHER | 9062538 | 01 | NY | CIGNA HEALTH PLANS | OTHER |