Provider Demographics
NPI:1184601072
Name:PANETTA, THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:PANETTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 NORTHERN BLVD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5206
Mailing Address - Country:US
Mailing Address - Phone:516-482-8220
Mailing Address - Fax:516-482-8221
Practice Address - Street 1:600 NORTHERN BLVD
Practice Address - Street 2:SUITE 115
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5206
Practice Address - Country:US
Practice Address - Phone:516-482-8220
Practice Address - Fax:516-482-8221
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1379782086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00799404Medicaid
NYA96888Medicare UPIN
NY00799404Medicaid
NY770002551Medicare PIN