Provider Demographics
NPI:1417008194
Name:MICHAEL DESPOSITO MD
Entity Type:Organization
Organization Name:MICHAEL DESPOSITO MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DESPOSITO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-269-1148
Mailing Address - Street 1:121 EAST NORTHPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754
Mailing Address - Country:US
Mailing Address - Phone:631-269-1148
Mailing Address - Fax:631-269-1149
Practice Address - Street 1:121 EAST NORTHPORT ROAD
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754
Practice Address - Country:US
Practice Address - Phone:631-269-1148
Practice Address - Fax:631-269-1149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty