Healthcare Provider Details

I. General information

NPI: 1760777486
Provider Name (Legal Business Name): GERALD DIMASO MDPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 SEGUINE AVE
STATEN ISLAND NY
10309-3723
US

IV. Provider business mailing address

69 SEGUINE AVENUE
STATEN ISLAND NY
10309
US

V. Phone/Fax

Practice location:
  • Phone: 718-356-6500
  • Fax: 718-356-0348
Mailing address:
  • Phone: 718-356-6500
  • Fax: 718-356-0348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number170623
License Number StateNY

VIII. Authorized Official

Name: DR. GERALD GENNARO DIMASO
Title or Position: PRESIDENT
Credential: MD
Phone: 718-356-6500