Provider Demographics
NPI:1487711941
Name:OPISSO, LAWRENCE A (DC)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:A
Last Name:OPISSO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1253 MONTAUK HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4916
Mailing Address - Country:US
Mailing Address - Phone:631-661-1400
Mailing Address - Fax:631-661-5242
Practice Address - Street 1:1253 MONTAUK HIGHWAY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4916
Practice Address - Country:US
Practice Address - Phone:631-661-1400
Practice Address - Fax:631-661-5242
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX4173111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
P52752Medicare UPIN
NYX23671Medicare ID - Type Unspecified