Basic Information
| Provider Information | |||||||||
| NPI: | 1770550477 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STONY BROOK GYNECOLOGY & OBSTETRICS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 RESEARCH WAY STE 105 | ||||||||
| Address2: | |||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117336401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316752125 | ||||||||
| FaxNumber: | 6316752624 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317519595 | ||||||||
| FaxNumber: | 6317512322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 07/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | FUNT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6317519595 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | WEP881 | 01 | NY | PTAN | OTHER |