Provider Demographics
NPI:1417920208
Name:FRUTH GIACOBBE, CHRISTINE M (DO)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:M
Last Name:FRUTH GIACOBBE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9 MEDICAL DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1591
Mailing Address - Country:US
Mailing Address - Phone:631-473-3900
Mailing Address - Fax:631-474-4475
Practice Address - Street 1:9 MEDICAL DR
Practice Address - Street 2:SUITE B
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1591
Practice Address - Country:US
Practice Address - Phone:631-473-3900
Practice Address - Fax:631-474-4475
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2314361207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG02064Medicare UPIN
NY15333WP541Medicare PIN