Healthcare Provider Details

I. General information

NPI: 1942201496
Provider Name (Legal Business Name): PETER LOFASO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 E MAIN ST
ENDICOTT NY
13760-5430
US

IV. Provider business mailing address

346 GRAND AVE
JOHNSON CITY NY
13790-2558
US

V. Phone/Fax

Practice location:
  • Phone: 607-754-7171
  • Fax: 607-754-0290
Mailing address:
  • Phone: 607-754-7171
  • Fax: 607-754-0290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number159393
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: