Provider Demographics
NPI:1972638450
Name:SEGUERRA-LAURIELLO, GLORIA M (MD)
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:M
Last Name:SEGUERRA-LAURIELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 AUDUBON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-3403
Mailing Address - Country:US
Mailing Address - Phone:212-342-9495
Mailing Address - Fax:212-740-6693
Practice Address - Street 1:515 AUDUBON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-3403
Practice Address - Country:US
Practice Address - Phone:212-342-9495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102406207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY008619090Medicaid
NY008619090Medicaid
NYB15789Medicare UPIN