Healthcare Provider Details

I. General information

NPI: 1366521445
Provider Name (Legal Business Name): C CORINA GERONTIS MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 VETERANS MEMORIAL HWY SUITE 101
COMMACK NY
11725-4233
US

IV. Provider business mailing address

PO BOX 595
COMMACK NY
11725-0595
US

V. Phone/Fax

Practice location:
  • Phone: 631-439-5440
  • Fax: 631-439-5447
Mailing address:
  • Phone: 631-439-5440
  • Fax: 631-439-5447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number188154
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01569231
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: CATHERINE C GERONTIS
Title or Position: MD
Credential: MD
Phone: 631-439-5440