Provider Demographics
NPI:1164457495
Name:SALVATORE, LIBERATO (MD)
Entity Type:Individual
Prefix:
First Name:LIBERATO
Middle Name:
Last Name:SALVATORE
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 1:36-35 BELL BLVD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361
Mailing Address - Country:US
Mailing Address - Phone:718-224-2199
Mailing Address - Fax:718-224-3060
Practice Address - Street 1:36-35 BELL BLVD.
Practice Address - Street 2:SUITE 100
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361
Practice Address - Country:US
Practice Address - Phone:718-224-2199
Practice Address - Fax:718-224-3060
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176514207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01355100Medicaid
NYF25733Medicare UPIN
NY02711CMedicare PIN
F25733Medicare UPIN
NY0271FJMedicare ID - Type Unspecified
NY01355100Medicaid