Provider Demographics
NPI:1265549356
Name:FESTA, ROBERT S (MD, LIC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:S
Last Name:FESTA
Suffix:
Gender:M
Credentials:MD, LIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1823
Mailing Address - Country:US
Mailing Address - Phone:631-588-4442
Mailing Address - Fax:631-471-3039
Practice Address - Street 1:270 UNION AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1823
Practice Address - Country:US
Practice Address - Phone:631-588-4442
Practice Address - Fax:631-471-3039
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1182542080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01281718Medicaid
NY01281718Medicaid