Provider Demographics
NPI:1518037241
Name:MARASIGAN, ANTONIO V (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:V
Last Name:MARASIGAN
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 1:104 UNION AVE STE 805
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1844
Mailing Address - Country:US
Mailing Address - Phone:315-474-7847
Mailing Address - Fax:315-474-3714
Practice Address - Street 1:104 UNION AVE STE 805
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1844
Practice Address - Country:US
Practice Address - Phone:315-474-7847
Practice Address - Fax:315-474-3714
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY601135972084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00478079Medicaid
B79059Medicare UPIN
NY00478079Medicaid