Provider Demographics
NPI:1871788273
Name:DIMILIA, MARY JO (MD)
Entity type:Individual
Prefix:DR
First Name:MARY JO
Middle Name:
Last Name:DIMILIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1244
Mailing Address - Country:US
Mailing Address - Phone:212-348-1454
Mailing Address - Fax:
Practice Address - Street 1:1150 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1244
Practice Address - Country:US
Practice Address - Phone:347-746-2144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-09
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197284-1207RA0000X
NY197284208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF49064Medicare PIN