Provider Demographics
NPI:1578550596
Name:POLISENO, MARINO A (DO)
Entity Type:Individual
Prefix:MR
First Name:MARINO
Middle Name:A
Last Name:POLISENO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 CLOVE RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3627
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:
Practice Address - Street 1:1050 CLOVE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3627
Practice Address - Country:US
Practice Address - Phone:718-442-4300
Practice Address - Fax:718-816-8369
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225825207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7166589OtherAETNA
NY02590985Medicaid
0297012OtherGHI
0297012OtherGHI
I18459Medicare UPIN