Provider Demographics
NPI:1043391592
Name:DIFATTA, GARY GASPER (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:GASPER
Last Name:DIFATTA
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 1:113 A SOUTH WELLWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757
Mailing Address - Country:US
Mailing Address - Phone:631-225-7630
Mailing Address - Fax:631-225-7653
Practice Address - Street 1:113 A SOUTH WELLWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757
Practice Address - Country:US
Practice Address - Phone:631-225-7630
Practice Address - Fax:631-225-7653
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX06832-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11-3168353OtherTAX ID
NY11-3168353OtherTAX ID