Provider Demographics
NPI:1043386402
Name:INGENITO, GENNARO P (MD)
Entity Type:Individual
Prefix:
First Name:GENNARO
Middle Name:P
Last Name:INGENITO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 BROADWAY
Mailing Address - Street 2:SUITE 303
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701
Mailing Address - Country:US
Mailing Address - Phone:631-789-7261
Mailing Address - Fax:631-789-8571
Practice Address - Street 1:221 BROADWAY
Practice Address - Street 2:SUITE 303
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701
Practice Address - Country:US
Practice Address - Phone:631-789-7261
Practice Address - Fax:631-789-8571
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1047872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00377826Medicaid
957561Medicare ID - Type Unspecified
NY00377826Medicaid