Provider Demographics
NPI:1942201496
Name:LOFASO, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:LOFASO
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2558
Mailing Address - Country:US
Mailing Address - Phone:607-754-7171
Mailing Address - Fax:607-754-0290
Practice Address - Street 1:1302 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-5430
Practice Address - Country:US
Practice Address - Phone:607-754-7171
Practice Address - Fax:607-754-0290
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY159393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00966376Medicaid
001186471-0001OtherPA MEDICAID
NY00966376Medicaid
CC6011Medicare PIN