Provider Demographics
NPI:1043446941
Name:TERESELLA GONDOLO, MDPC
Entity Type:Organization
Organization Name:TERESELLA GONDOLO, MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:TERESELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONDOLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-803-2400
Mailing Address - Street 1:PO BOX 1393
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0011
Mailing Address - Country:US
Mailing Address - Phone:718-803-2400
Mailing Address - Fax:718-803-2436
Practice Address - Street 1:3717 91ST ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7927
Practice Address - Country:US
Practice Address - Phone:718-803-2400
Practice Address - Fax:718-803-2436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194211174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG24578Medicare UPIN