Provider Demographics
NPI:1043271752
Name:BERTOLINO, JACK G (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:G
Last Name:BERTOLINO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5320 MILITARY RD
Mailing Address - Street 2:SUITE #104
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092-2149
Mailing Address - Country:US
Mailing Address - Phone:716-297-1153
Mailing Address - Fax:716-297-5458
Practice Address - Street 1:5320 MILITARY RD
Practice Address - Street 2:SUITE #104
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-2149
Practice Address - Country:US
Practice Address - Phone:716-297-1153
Practice Address - Fax:716-297-5458
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY180670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11357AMedicare ID - Type Unspecified
NYE45144Medicare UPIN