Provider Demographics
NPI:1053387613
Name:FASTIGGI, RICHARD JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOSEPH
Last Name:FASTIGGI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:130 CENTER WAY
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-2255
Practice Address - Country:US
Practice Address - Phone:607-936-9971
Practice Address - Fax:607-936-2600
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040004E207RG0100X
NY171866-1207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAGU039871OtherMEDICARE GROUP
PA001097790002Medicaid
NYCC8362OtherRR MEDICARE GROUP
NY01035905Medicaid
PA110209180OtherRR MEDICARE PIN
B82784Medicare UPIN
NY50210WMedicare ID - Type Unspecified
PA110209180OtherRR MEDICARE PIN