Provider Demographics
NPI:1477526531
Name:DIMASO, GERALD GENNARO (MD)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:GENNARO
Last Name:DIMASO
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 1:39 DORA LN
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-1672
Mailing Address - Country:US
Mailing Address - Phone:732-888-1975
Mailing Address - Fax:
Practice Address - Street 1:68 SEGUINE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-3723
Practice Address - Country:US
Practice Address - Phone:718-356-6500
Practice Address - Fax:718-356-0348
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170623207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01119180Medicaid
NY01119180Medicaid
NYA61565Medicare UPIN