Basic Information
| Provider Information | |||||||||
| NPI: | 1902903099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAPOBIANCO | ||||||||
| FirstName: | LUIGI | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 972 BRUSH HOLLOW RD | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115901740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168765555 | ||||||||
| FaxNumber: | 5168765539 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SCHOOL ST | ||||||||
| Address2: | |||||||||
| City: | GLEN COVE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115422545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166719800 | ||||||||
| FaxNumber: | 5166719283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 02/05/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 174738 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01463932 | 05 | NY | MEDICAID |