Provider Demographics
NPI:1417093022
Name:DESPOSITO, ANTONIO G (DC)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:G
Last Name:DESPOSITO
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 1:290 SEGUINE AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309
Mailing Address - Country:US
Mailing Address - Phone:718-356-9469
Mailing Address - Fax:718-356-8139
Practice Address - Street 1:290 SEGUINE AVENUE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309
Practice Address - Country:US
Practice Address - Phone:718-356-9469
Practice Address - Fax:718-356-8139
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0089091111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U70593Medicare UPIN
X7A481Medicare ID - Type Unspecified