Provider Demographics
NPI:1891705570
Name:GRISTINA, JEROME A A (MD)
Entity Type:Individual
Prefix:MR
First Name:JEROME A
Middle Name:A
Last Name:GRISTINA
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 1:150 LOCKWOOD AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801
Mailing Address - Country:US
Mailing Address - Phone:914-636-4466
Mailing Address - Fax:914-636-0611
Practice Address - Street 1:150 LOCKWOOD AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801
Practice Address - Country:US
Practice Address - Phone:914-636-4466
Practice Address - Fax:914-636-0611
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0866131208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00134634Medicaid
B11814Medicare UPIN
260491Medicare ID - Type Unspecified