Provider Demographics
NPI:1871544015
Name:THREE VILLAGE NEUROLOGY, P.C.
Entity type:Organization
Organization Name:THREE VILLAGE NEUROLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-751-0790
Mailing Address - Street 1:4511 NESCONSET HWY
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2630
Mailing Address - Country:US
Mailing Address - Phone:631-751-0790
Mailing Address - Fax:631-675-1022
Practice Address - Street 1:4511 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2630
Practice Address - Country:US
Practice Address - Phone:631-751-0790
Practice Address - Fax:631-675-1022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234763174400000X
2084E0001X, 2084N0400X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No2084E0001XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyEpilepsyGroup - Multi-Specialty
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2084N0400XOtherTAXONOMY
I34562Medicare UPIN
607N51Medicare PIN