Provider Demographics
NPI:1679682702
Name:PASSARELLI, JOHN GABRIEL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GABRIEL
Last Name:PASSARELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 SUFFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4309
Mailing Address - Country:US
Mailing Address - Phone:631-231-4455
Mailing Address - Fax:631-231-5421
Practice Address - Street 1:601 SUFFOLK AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4309
Practice Address - Country:US
Practice Address - Phone:631-231-4455
Practice Address - Fax:631-231-5421
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY140081207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02492253Medicaid
NYB18966Medicare UPIN
NY02492253Medicaid