Provider Demographics
NPI:1124000864
Name:DECUNZO, LOUIS PETER JR (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:PETER
Last Name:DECUNZO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 PARK STREET
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:518-926-5924
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:14 HUDSON AVENUE
Practice Address - Street 2:SURGICAL SPECIALISTS OF GLENS FALLS HOSPITAL
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4443
Practice Address - Country:US
Practice Address - Phone:518-926-5600
Practice Address - Fax:518-926-5605
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY201484208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01617601Medicaid
NYP00402831OtherRR MEDICARE
NY01617601Medicaid
F82616Medicare UPIN