Provider Demographics
NPI:1639271810
Name:PERILLI, GAETANO (MD)
Entity Type:Individual
Prefix:
First Name:GAETANO
Middle Name:
Last Name:PERILLI
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 1:3004 ROBERTS AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461
Mailing Address - Country:US
Mailing Address - Phone:718-931-8041
Mailing Address - Fax:718-931-5815
Practice Address - Street 1:3004 ROBERTS AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-931-8041
Practice Address - Fax:718-931-5815
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01889761Medicaid
G92275Medicare UPIN
NY4Y0072Medicare ID - Type Unspecified