Provider Demographics
NPI:1124018221
Name:DETESO, DAMON J (MD)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:J
Last Name:DETESO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 AUTOMATION LN
Mailing Address - Street 2:STE 125
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1660
Mailing Address - Country:US
Mailing Address - Phone:518-275-7126
Mailing Address - Fax:
Practice Address - Street 1:211 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SARATOGA SPGS
Practice Address - State:NY
Practice Address - Zip Code:12866-1046
Practice Address - Country:US
Practice Address - Phone:518-583-8461
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-28
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2336922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H93014Medicare UPIN
RA4297Medicare ID - Type Unspecified