Provider Demographics
NPI:1710935713
Name:RESTIVO, JOHN RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:RESTIVO
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 1:185 GENESEE ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-2199
Mailing Address - Country:US
Mailing Address - Phone:315-793-8806
Mailing Address - Fax:315-793-8046
Practice Address - Street 1:1500 N JAMES ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2844
Practice Address - Country:US
Practice Address - Phone:315-338-7029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2074642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY040426013913OtherFIDELIS
NY207464-9OtherWC
NYP010207464OtherBCBS
NY01754118Medicaid
NY4196774OtherGHI
NY10045243OtherCDPHP
NY300080976OtherRAIL ROAD MEDICARE
NY958476OtherMVP
NY01647929Medicaid
NY958476OtherMVP
NY4196774OtherGHI
NYP010207464OtherBCBS
NY207464-9OtherWC