Provider Demographics
NPI:1508917287
Name:DESPOSITO, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DESPOSITO
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 1:121 EAST NORTHPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-2513
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:11754-2513
Practice Address - Country:US
Practice Address - Phone:631-269-1148
Practice Address - Fax:631-269-1149
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172535207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01207890Medicaid
E75681Medicare UPIN
NY35F231Medicare ID - Type Unspecified