Provider Demographics
NPI:1710974001
Name:GERVASIO, JOSEPH (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:GERVASIO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 N BROADWAY UNIT B
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2451
Mailing Address - Country:US
Mailing Address - Phone:516-799-0550
Mailing Address - Fax:516-799-0562
Practice Address - Street 1:838 N BROADWAY UNIT B
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2451
Practice Address - Country:US
Practice Address - Phone:516-799-0550
Practice Address - Fax:516-799-0562
Is Sole Proprietor?:No
Enumeration Date:2005-10-01
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNOO3169-1213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00586434Medicaid
NYT50977Medicare UPIN
NYP33611Medicare ID - Type Unspecified
NYP33612Medicare PIN