Provider Demographics
NPI:1851457477
Name:CONSIGLIERE, GINO A (MD)
Entity Type:Individual
Prefix:
First Name:GINO
Middle Name:A
Last Name:CONSIGLIERE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MEDICAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1593
Mailing Address - Country:US
Mailing Address - Phone:631-928-5252
Mailing Address - Fax:631-928-5259
Practice Address - Street 1:7 MEDICAL DR STE A
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1593
Practice Address - Country:US
Practice Address - Phone:631-928-5252
Practice Address - Fax:631-928-5259
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY109169207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CCLI1312OtherVYTRA
GC0625781OtherBLUE CROSS
692668OtherUNITER HEALTHCARE
NY182279OtherAETNA US HEALTH
AJ45668OtherMDNY
P44353103OtherMULITPLAN
AJ45668OtherMDNY
B17214Medicare UPIN