Basic Information
| Provider Information | |||||||||
| NPI: | 1154300689 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEVINCENZO | ||||||||
| FirstName: | SALVATORE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GRAND STREET | ||||||||
| Address2: | 3RD FL | ||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109901035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8459873906 | ||||||||
| FaxNumber: | 8459875979 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 HATFIELD LN | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109246734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452948888 | ||||||||
| FaxNumber: | 8452941669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 08/21/2017 | ||||||||
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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 | 207R00000X | 145343 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 145343 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 145343 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 00787357 | 05 | NY | MEDICAID | 110035384 | 01 | NY | RAILROAD MEDICARE PIN | OTHER |