Provider Demographics
NPI:1346224755
Name:MENENDEZ, DESI M (DC)
Entity Type:Individual
Prefix:
First Name:DESI
Middle Name:M
Last Name:MENENDEZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 GILBERT AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-5326
Mailing Address - Country:US
Mailing Address - Phone:631-265-8915
Mailing Address - Fax:631-265-8917
Practice Address - Street 1:20 GILBERT AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-5326
Practice Address - Country:US
Practice Address - Phone:631-265-8915
Practice Address - Fax:631-265-8917
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006087-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01738421Medicaid
NYX37091Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID #
NY01738421Medicaid