Basic Information
| Provider Information | |||||||||
| NPI: | 1669891370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLITO | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TISOVIC | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1530 FRONT ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | EAST MEADOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115542265 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1530 FRONT ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | EAST MEADOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115542265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163247500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2014 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | A155170 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.