Provider Demographics
NPI:1437508892
Name:ABBATIELLO, DAVID J
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:J
Last Name:ABBATIELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 MORGAN RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:NY
Mailing Address - Zip Code:13112-8717
Mailing Address - Country:US
Mailing Address - Phone:315-481-1557
Mailing Address - Fax:315-277-5007
Practice Address - Street 1:1116 MORGAN RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:NY
Practice Address - Zip Code:13112-8717
Practice Address - Country:US
Practice Address - Phone:315-481-1557
Practice Address - Fax:315-277-5007
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY657899026172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY464911199OtherFIDELIS CARE
NY03437116Medicaid