Provider Demographics
NPI:1740593094
Name:CRISTALLI, GAETANO MATTHEW (DO)
Entity Type:Individual
Prefix:DR
First Name:GAETANO
Middle Name:MATTHEW
Last Name:CRISTALLI
Suffix:
Gender:M
Credentials:DO
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 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:
Practice Address - Street 1:279 TROY RD
Practice Address - Street 2:FAMILY MEDICAL GROUP
Practice Address - City:RENSSELAER
Practice Address - State:NY
Practice Address - Zip Code:12144-9518
Practice Address - Country:US
Practice Address - Phone:518-286-1922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00473565Medicaid
NY331807Medicare PIN