Provider Demographics
NPI:1710197058
Name:CAPITAL DISTRICT GASTROENTEROLOGY & LIVER DISEASE, PC
Entity Type:Organization
Organization Name:CAPITAL DISTRICT GASTROENTEROLOGY & LIVER DISEASE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:PULEO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-489-7491
Mailing Address - Street 1:1 S PINE AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-2212
Mailing Address - Country:US
Mailing Address - Phone:518-489-7491
Mailing Address - Fax:518-489-3439
Practice Address - Street 1:1 S PINE AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-2212
Practice Address - Country:US
Practice Address - Phone:518-489-7491
Practice Address - Fax:518-489-3439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY088175-1208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00510292Medicaid
NY33603AMedicare ID - Type Unspecified
NY00510292Medicaid