Provider Demographics
NPI:1558580647
Name:GAVIOLA, MARIANO FREDERICO
Entity Type:Individual
Prefix:
First Name:MARIANO FREDERICO
Middle Name:
Last Name:GAVIOLA
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 1:2244 PALISADES CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WEST NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10994-6402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28B INDIAN ROCK
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:NY
Practice Address - Zip Code:10901-4907
Practice Address - Country:US
Practice Address - Phone:845-368-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014901-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ26U21Medicare ID - Type Unspecified