Provider Demographics
NPI:1407885825
Name:PESOLA, GENE R (MD)
Entity Type:Individual
Prefix:
First Name:GENE
Middle Name:R
Last Name:PESOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:1981 MARCUS AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1038
Mailing Address - Country:US
Mailing Address - Phone:718-670-1651
Mailing Address - Fax:516-437-4167
Practice Address - Street 1:2525 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1705
Practice Address - Country:US
Practice Address - Phone:718-692-5300
Practice Address - Fax:516-437-4167
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2010-11-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY151334207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01123151Medicaid
NY110099188Medicare PIN
NY18E401Medicare ID - Type Unspecified
NY01123151Medicaid