Basic Information
| Provider Information | |||||||||
| NPI: | 1336196328 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DETRAGLIA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2211 GENESEE ST | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135015930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157337798 | ||||||||
| FaxNumber: | 3157337893 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 GENESEE ST | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135015930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157337798 | ||||||||
| FaxNumber: | 3157337893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 116168-1 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00455743 | 05 | NY | MEDICAID |