Basic Information
| Provider Information | |||||||||
| NPI: | 1356380612 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYLOTTE | ||||||||
| FirstName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1191 BOWEN RD | ||||||||
| Address2: | |||||||||
| City: | ELMA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140599546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166552690 | ||||||||
| FaxNumber: | 7166552692 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 N FOREST RD | ||||||||
| Address2: | |||||||||
| City: | GETZVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140681527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166393311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 07/26/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 120404 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1356380612 | 01 | NY | UNIVERA HEALTHCARE | OTHER | 3407611 | 01 | NY | INDEPENDENT HEALTH | OTHER | 00010124401 | 01 | NY | EXCELLUS UNIVERA | OTHER | 005104233 | 01 | NY | HEALTH NOW | OTHER | 01150852 | 05 | NY | MEDICAID |