Provider Demographics
NPI:1134174048
Name:PANTIG, EMIDIO R (MD)
Entity type:Individual
Prefix:DR
First Name:EMIDIO
Middle Name:R
Last Name:PANTIG
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 1:6865 FRESH POND RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-5263
Mailing Address - Country:US
Mailing Address - Phone:718-456-8200
Mailing Address - Fax:718-366-7586
Practice Address - Street 1:6865 FRESH POND RD
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5263
Practice Address - Country:US
Practice Address - Phone:718-456-8200
Practice Address - Fax:718-366-7586
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158443174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0061091OtherGHI PROVIDER NUMBER
NY00840400Medicaid
NY0061091OtherGHI PROVIDER NUMBER
NY29D761Medicare ID - Type UnspecifiedCMS MEDICARE NUMBER
NY00840400Medicaid