Provider Demographics
NPI:1376648634
Name:DESHAIES, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DESHAIES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-0587
Mailing Address - Country:US
Mailing Address - Phone:860-258-3480
Mailing Address - Fax:860-571-6800
Practice Address - Street 1:704 HEBRON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-5020
Practice Address - Country:US
Practice Address - Phone:860-659-1379
Practice Address - Fax:860-659-4648
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038635207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH28428Medicare UPIN