Provider Demographics
NPI:1588622237
Name:DE GENNARO, VINCENT P (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:P
Last Name:DE GENNARO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3936 AMBOY RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308
Mailing Address - Country:US
Mailing Address - Phone:718-966-0066
Mailing Address - Fax:718-227-0602
Practice Address - Street 1:3936 AMBOY RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308
Practice Address - Country:US
Practice Address - Phone:718-966-0066
Practice Address - Fax:718-227-0602
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164097207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
25E031Medicare ID - Type Unspecified
A61566Medicare UPIN