Basic Information
| Provider Information | |||||||||
| NPI: | 1386682565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAO | ||||||||
| FirstName: | ROGELIO | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453000 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Practice Location | |||||||||
| Address1: | 34 COMMERCE AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119013118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317228880 | ||||||||
| FaxNumber: | 6317227851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 10/26/2012 | ||||||||
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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 | 208000000X | 103078 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00649243 | 05 | NY | MEDICAID |