Provider Demographics
NPI:1730253378
Name:FAHEY, JULIA (MD)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:FAHEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3003
Mailing Address - Country:US
Mailing Address - Phone:631-687-2969
Mailing Address - Fax:631-687-2970
Practice Address - Street 1:105 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3003
Practice Address - Country:US
Practice Address - Phone:631-687-2969
Practice Address - Fax:631-687-2970
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169349207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01397617Medicaid
NY55F151Medicare ID - Type Unspecified
NY01397617Medicaid