Provider Demographics
NPI:1548288988
Name:DESIMONE, JOHN P (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:DESIMONE
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 1:475 IRVING AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1528
Mailing Address - Country:US
Mailing Address - Phone:315-464-4686
Mailing Address - Fax:315-464-7106
Practice Address - Street 1:475 IRVING AVE
Practice Address - Street 2:STE 300
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1528
Practice Address - Country:US
Practice Address - Phone:315-464-4686
Practice Address - Fax:315-464-7106
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104285207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4216626OtherAETNA
NY00482453Medicaid
34820CMedicare ID - Type Unspecified
B81229Medicare UPIN