1174518120 NPI number — DR. PETER A TOMASELLO JR. DO

Table of content: DR. PETER A TOMASELLO JR. DO (NPI 1174518120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174518120 NPI number — DR. PETER A TOMASELLO JR. DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TOMASELLO
Provider First Name:
PETER
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174518120
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/23/2006
NPI Reactivation Date:
03/27/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAMESTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14701-6626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-488-1877
Provider Business Mailing Address Fax Number:
716-488-1986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 FOOTE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMESTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14701-7077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-483-5306
Provider Business Practice Location Address Fax Number:
716-483-5307
Provider Enumeration Date:
09/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  OS7358 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 253152601 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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