Healthcare Provider Details

I. General information

NPI: 1336158542
Provider Name (Legal Business Name): KARL A DESHRAGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 EAST MAIN ST SOUTH BROOKHAVEN HEALTH CENTER WEST
PATCHOQUE NY
11772
US

IV. Provider business mailing address

365 EAST MAIN ST SOUTH BROOKHAVEN HEALTH CENTER WEST
PATCHOQUE NY
11772
US

V. Phone/Fax

Practice location:
  • Phone: 631-854-1307
  • Fax: 631-854-1310
Mailing address:
  • Phone: 631-854-1307
  • Fax: 631-854-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number132912
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: