Provider Demographics
NPI:1639148208
Name:DIFELICE, GREGORY SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
Last Name:DIFELICE
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 1:954 LEXINGTON AVE # 700
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5055
Mailing Address - Country:US
Mailing Address - Phone:631-329-6925
Mailing Address - Fax:631-329-6951
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021
Practice Address - Country:US
Practice Address - Phone:212-746-4993
Practice Address - Fax:212-746-8744
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202532207XS0114X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02152321Medicaid
NY02152321Medicaid
NYA400088654Medicare PIN
NYA400022269Medicare PIN
NY653G61Medicare PIN
NY653G633901Medicare PIN