Provider Demographics
NPI:1336812627
Name:GIANNETTO, MICHAEL WILLIAM
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:GIANNETTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 HAGERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-5581
Mailing Address - Country:US
Mailing Address - Phone:631-352-9296
Mailing Address - Fax:
Practice Address - Street 1:234 HAGERMAN AVE
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-5581
Practice Address - Country:US
Practice Address - Phone:631-352-9296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-01
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty