Provider Demographics
NPI:1689759672
Name:PRIOLEAU, PHILIP GENDRON (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:GENDRON
Last Name:PRIOLEAU
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 1:1035 5TH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0135
Mailing Address - Country:US
Mailing Address - Phone:212-794-3548
Mailing Address - Fax:212-794-2203
Practice Address - Street 1:1035 5TH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0135
Practice Address - Country:US
Practice Address - Phone:212-794-3548
Practice Address - Fax:212-794-2203
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140641174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB17012Medicare UPIN