Basic Information
| Provider Information | |||||||||
| NPI: | 1255702569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACARIO | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
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| OtherLastName: | MACARIO | ||||||||
| OtherFirstName: | THEODORE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 370 W 2ND ST | ||||||||
| Address2: | |||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117952429 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7901 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183343050 | ||||||||
| FaxNumber: | 7183343015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2015 | ||||||||
| LastUpdateDate: | 10/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.