Provider Demographics
NPI:1649222704
Name:NORONHA, GARY JOHN (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JOHN
Last Name:NORONHA
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 1:2300 W JEFFERSON RD STE 400
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-1090
Mailing Address - Country:US
Mailing Address - Phone:585-427-9950
Mailing Address - Fax:585-424-2788
Practice Address - Street 1:2300 W JEFFERSON RD STE 400
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-1090
Practice Address - Country:US
Practice Address - Phone:585-427-9950
Practice Address - Fax:585-424-1013
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268181363AM0700X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03532890Medicaid
MD359412200Medicaid
MDH71544Medicare UPIN
MDF668Medicare ID - Type UnspecifiedINDIVIDUAL