Provider Demographics
NPI:1689260598
Name:LONTRATO, GINO ANTHONY
Entity Type:Individual
Prefix:
First Name:GINO
Middle Name:ANTHONY
Last Name:LONTRATO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 VIALL AVE
Mailing Address - Street 2:
Mailing Address - City:MECHANICVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12118-1032
Mailing Address - Country:US
Mailing Address - Phone:518-269-0011
Mailing Address - Fax:518-708-8780
Practice Address - Street 1:39 VIALL AVE
Practice Address - Street 2:
Practice Address - City:MECHANICVILLE
Practice Address - State:NY
Practice Address - Zip Code:12118-1032
Practice Address - Country:US
Practice Address - Phone:518-269-0011
Practice Address - Fax:518-708-8780
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY577496321172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver