Provider Demographics
NPI:1174518120
Name:TOMASELLO, PETER A JR (DO)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:A
Last Name:TOMASELLO
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6626
Mailing Address - Country:US
Mailing Address - Phone:716-488-1877
Mailing Address - Fax:716-488-1986
Practice Address - Street 1:207 FOOTE AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-7077
Practice Address - Country:US
Practice Address - Phone:716-483-5306
Practice Address - Fax:716-483-5307
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2016-07-22
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
FLOS7358207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253152601Medicaid
FL41963AMedicare ID - Type Unspecified
FL253152601Medicaid