Basic Information
| Provider Information | |||||||||
| NPI: | 1225050412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PIKE | ||||||||
| FirstName: | SHELDON | ||||||||
| MiddleName: | BRUCE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 ROUTE 112 STE 101 | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117768054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513000 | ||||||||
| FaxNumber: | 6317510506 | ||||||||
| Practice Location | |||||||||
| Address1: | 1185 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | HEWLETT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115572323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162398877 | ||||||||
| FaxNumber: | 5162391104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 168657 | NY | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 01188678 | 05 | NY | MEDICAID |