Provider Demographics
NPI:1710982616
Name:PISANIELLO, DANIEL P (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:P
Last Name:PISANIELLO
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:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:LYONS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13368-0247
Mailing Address - Country:US
Mailing Address - Phone:315-701-5610
Mailing Address - Fax:315-701-5608
Practice Address - Street 1:3926 STATE ROUTE 12
Practice Address - Street 2:
Practice Address - City:LYONS FALLS
Practice Address - State:NY
Practice Address - Zip Code:13368-1919
Practice Address - Country:US
Practice Address - Phone:315-348-8407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176752207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01161302Medicaid
54933CMedicare PIN
D48885Medicare UPIN
NY01161302Medicaid
NYP00292798Medicare PIN