Healthcare Provider Details

I. General information

NPI: 1164659066
Provider Name (Legal Business Name): MARIE DESALES O'DOWD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 READE PL DYSIN CENTER, 2ND FLOOR
POUGHKEEPSIE NY
12601-3947
US

IV. Provider business mailing address

1351 ROUTE 55 SUITE 200
LAGRANGEVILLE NY
12540-5108
US

V. Phone/Fax

Practice location:
  • Phone: 845-483-6920
  • Fax:
Mailing address:
  • Phone: 945-475-9661
  • Fax: 845-475-9938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number019420
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number019420
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: