Provider Demographics
NPI:1780639419
Name:GARGIULO, JUAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:J
Last Name:GARGIULO
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 5072
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11969-5072
Mailing Address - Country:US
Mailing Address - Phone:631-702-2300
Mailing Address - Fax:631-702-2303
Practice Address - Street 1:365 COUNTY ROAD 39A
Practice Address - Street 2:SUITE 15 & 16
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5284
Practice Address - Country:US
Practice Address - Phone:631-702-2300
Practice Address - Fax:631-702-2303
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181791207L00000X, 207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01355302Medicaid
NY01355302Medicaid
24L59EK251Medicare PIN