Healthcare Provider Details

I. General information

NPI: 1528161338
Provider Name (Legal Business Name): MICHAEL DEJESUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 03/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7980 STATE ROUTE 12
BARNEVELD NY
13304-2536
US

IV. Provider business mailing address

5596 MILITARY RD
REMSEN NY
13438-6008
US

V. Phone/Fax

Practice location:
  • Phone: 315-624-8440
  • Fax: 315-624-5113
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number137801
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: