Provider Demographics
NPI:1760777486
Name:GERALD DIMASO MDPC
Entity Type:Organization
Organization Name:GERALD DIMASO MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:GENNARO
Authorized Official - Last Name:DIMASO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-356-6500
Mailing Address - Street 1:69 SEGUINE AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309
Mailing Address - Country:US
Mailing Address - Phone:718-356-6500
Mailing Address - Fax:718-356-0348
Practice Address - Street 1:68 SEGUINE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-3723
Practice Address - Country:US
Practice Address - Phone:718-356-6500
Practice Address - Fax:718-356-0348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170623261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
25EO21Medicare PIN