Provider Demographics
NPI:1417206079
Name:PASTORI, LUCIANO JUAN (MD)
Entity Type:Individual
Prefix:
First Name:LUCIANO
Middle Name:JUAN
Last Name:PASTORI
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 1:240 E 90TH ST APT 3B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-3577
Mailing Address - Country:US
Mailing Address - Phone:347-337-4374
Mailing Address - Fax:
Practice Address - Street 1:10211 ROOSEVELT AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2331
Practice Address - Country:US
Practice Address - Phone:718-898-1386
Practice Address - Fax:718-898-3673
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY273508207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03967508Medicaid