Basic Information
| Provider Information | |||||||||
| NPI: | 1730325721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAETANO | ||||||||
| FirstName: | THELMA | ||||||||
| MiddleName: | BARKER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAETANO | ||||||||
| OtherFirstName: | THEMELINA | ||||||||
| OtherMiddleName: | BARKER | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 COMMACK RD UNIT 206 | ||||||||
| Address2: | |||||||||
| City: | COMMACK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117255022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316752125 | ||||||||
| FaxNumber: | 6316752628 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 MEETING HOUSE LN | ||||||||
| Address2: | |||||||||
| City: | SOUTHAMPTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119685087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312837733 | ||||||||
| FaxNumber: | 6312833183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2008 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35.088709 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 307332 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3153555 | 05 | OH | MEDICAID |