Provider Demographics
NPI:1992045470
Name:AIDALA, MARYJO
Entity Type:Individual
Prefix:
First Name:MARYJO
Middle Name:
Last Name:AIDALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1658 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-4029
Mailing Address - Country:US
Mailing Address - Phone:518-428-4948
Mailing Address - Fax:
Practice Address - Street 1:1658 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4029
Practice Address - Country:US
Practice Address - Phone:518-428-4948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22CA0238513174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist