Basic Information
| Provider Information | |||||||||
| NPI: | 1992791479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIANNONE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077298156 | ||||||||
| FaxNumber: | 6074676219 | ||||||||
| Practice Location | |||||||||
| Address1: | 53 PINE ST | ||||||||
| Address2: | DEPOSIT FAMILY CARE CENTER | ||||||||
| City: | DEPOSIT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137541301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074674195 | ||||||||
| FaxNumber: | 6074676219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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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 | 207Q00000X | 1618701 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 161870 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009395960 | 05 | NY | MEDICAID |