MEDICARE: VINCENT P DE GENNARO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	164097	NY

General Provider Information

NPI Number	:	1588622237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VINCENT P DE GENNARO MD

Provider Business Mailing Address
First Line	:	3936 AMBOY RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10308
Country	:	US
Telephone Number	:	718-966-0066
Fax Number	:	718-227-0602

Provider Business Practice Location Address
First Line	:	3936 AMBOY RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10308
Country	:	US
Telephone Number	:	718-966-0066
Fax Number	:	718-227-0602

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	07/08/2007

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