Provider Demographics
NPI:1801807037
Name:ANSELMO D. DEASIS M.D.
Entity type:Organization
Organization Name:ANSELMO D. DEASIS M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:ANSELMO
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEASIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-776-9198
Mailing Address - Street 1:111 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:14903-1303
Mailing Address - Country:US
Mailing Address - Phone:607-734-9539
Mailing Address - Fax:607-734-6293
Practice Address - Street 1:7433 STATE ROUTE 54
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810
Practice Address - Country:US
Practice Address - Phone:607-776-9198
Practice Address - Fax:607-776-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184984207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01267674Medicaid
NY01267674Medicaid
NYAA1240Medicare PIN