Provider Demographics
NPI:1346218930
Name:GAUDINO, WALTER JAMES (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:JAMES
Last Name:GAUDINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:175 JERICHO TPKE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4532
Mailing Address - Country:US
Mailing Address - Phone:516-364-3382
Mailing Address - Fax:516-364-3485
Practice Address - Street 1:175 JERICHO TPKE
Practice Address - Street 2:SUITE 102
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4532
Practice Address - Country:US
Practice Address - Phone:516-364-3382
Practice Address - Fax:516-362-3485
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY185629-1208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00125851Medicaid
NYE98545Medicare UPIN
NY00125851Medicaid