Provider Demographics
NPI:1396858205
Name:PACIFICO, FERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:PACIFICO
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 1:60 QUEENS ST
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-3058
Mailing Address - Country:US
Mailing Address - Phone:718-702-7216
Mailing Address - Fax:831-603-0351
Practice Address - Street 1:60 QUEENS ST
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-3058
Practice Address - Country:US
Practice Address - Phone:718-702-7216
Practice Address - Fax:718-831-6030
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY141745207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY45A341Medicare PIN