Provider Demographics
NPI:1659470391
Name:PELLERIN, EUGENE R JR (DO)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:R
Last Name:PELLERIN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:GENE
Other - Middle Name:R
Other - Last Name:PELLERIN
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:512-852-5563
Mailing Address - Fax:518-649-4094
Practice Address - Street 1:1 NORTON AVE
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820
Practice Address - Country:US
Practice Address - Phone:607-431-5305
Practice Address - Fax:607-431-5723
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218574207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02543846Medicaid
NY02543846Medicaid
NYG91733Medicare UPIN