Provider Demographics
NPI:1043236375
Name:POLIDORO, MICHAEL (PA)
Entity type:Individual
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First Name:MICHAEL
Middle Name:
Last Name:POLIDORO
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Gender:M
Credentials:PA
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Mailing Address - Street 1:375 E MAIN ST
Mailing Address - Street 2:STE 1
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8418
Mailing Address - Country:US
Mailing Address - Phone:631-665-8790
Mailing Address - Fax:631-665-1581
Practice Address - Street 1:375 E MAIN ST
Practice Address - Street 2:STE 1
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8418
Practice Address - Country:US
Practice Address - Phone:631-665-8790
Practice Address - Fax:631-665-1581
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
NY009063363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant