Provider Demographics
NPI:1144322744
Name:GUALTIERI, NICHOLAS (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GUALTIERI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 W 12 STREET
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8520
Mailing Address - Country:US
Mailing Address - Phone:646-638-1528
Mailing Address - Fax:
Practice Address - Street 1:59 W 12TH ST
Practice Address - Street 2:SUITE 1D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8520
Practice Address - Country:US
Practice Address - Phone:646-638-1528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109007207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY653701Medicare PIN
NY653701Medicare ID - Type Unspecified
B17564Medicare UPIN