Provider Demographics
NPI:1801826110
Name:SALLUSTO, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SALLUSTO
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 29140
Mailing Address - Street 2:SOUTH BAY ANESTHESIA
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-9140
Mailing Address - Country:US
Mailing Address - Phone:800-720-1664
Mailing Address - Fax:207-753-2020
Practice Address - Street 1:301 E MAIN ST
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8408
Practice Address - Country:US
Practice Address - Phone:631-968-3163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164350207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01106963Medicaid
050058326OtherRAILROAD MEDICARE
NY01106963Medicaid
NY30E431Medicare PIN