Provider Demographics
NPI:1508967456
Name:DEYESO, VERONICA O (MD)
Entity Type:Individual
Prefix:DR
First Name:VERONICA
Middle Name:O
Last Name:DEYESO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-6810
Mailing Address - Country:US
Mailing Address - Phone:413-443-9082
Mailing Address - Fax:413-443-0361
Practice Address - Street 1:261 SOUTH ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201
Practice Address - Country:US
Practice Address - Phone:413-443-9082
Practice Address - Fax:413-443-0361
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50760207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110064823AMedicaid
KYTP806OtherKY LICENSE
MA6181015Medicaid
KY7100461120Medicaid
MAJ03375Medicare PIN
A57005Medicare UPIN
KYTP806OtherKY LICENSE