Basic Information
| Provider Information | |||||||||
| NPI: | 1578563466 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GADIOMA | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 BARKER AVE | ||||||||
| Address2: | FL 4 | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106011509 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3 BARKER AVE | ||||||||
| Address2: | FL 4 | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106011509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149491199 | ||||||||
| FaxNumber: | 9149491245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 04/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 181083 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01565099 | 05 | NY | MEDICAID |