Provider Demographics
NPI:1558620690
Name:GIANNATTASIO, THERESA (DO)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:GIANNATTASIO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:203 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-3648
Practice Address - Country:US
Practice Address - Phone:973-992-5588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MB09286900208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program