Provider Demographics
NPI:1407056534
Name:FUGO-TUTALO, JONATHAN R (DO)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:R
Last Name:FUGO-TUTALO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:MR
Other - First Name:JONATHAN
Other - Middle Name:R
Other - Last Name:FUGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:92 OLD ROUTE 9W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-5485
Mailing Address - Country:US
Mailing Address - Phone:845-565-7040
Mailing Address - Fax:845-565-7060
Practice Address - Street 1:92 OLD ROUTE 9W
Practice Address - Street 2:SUITE 100
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-5485
Practice Address - Country:US
Practice Address - Phone:845-565-7040
Practice Address - Fax:845-565-7060
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260705208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03372070Medicaid
NY03372070Medicaid