Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | X007427-1 | NY |
NPI | 1790810232 |
---|---|
Provider Name | Mario Funicelli |
First Address | Staten Island, NY 10314-3889 |
Second Address | Staten Island, NY 10314-3889 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/02/2007 |
Last Update Date | 29/08/2014 |