Provider Demographics
NPI:1538909312
Name:GEMMATO VALECILLOS, MARIO ALFONSO (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:ALFONSO
Last Name:GEMMATO VALECILLOS
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 1:4316 34TH AVE APT 3F
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-1116
Mailing Address - Country:US
Mailing Address - Phone:619-317-7385
Mailing Address - Fax:
Practice Address - Street 1:7901 BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-3437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program