Provider Demographics
NPI:1629348941
Name:PERSOLEO, MICHAEL ANTHONY JR (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:PERSOLEO
Suffix:JR
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 1:3A2 CANDLEWYCK PARK
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1320
Mailing Address - Country:US
Mailing Address - Phone:607-272-0006
Mailing Address - Fax:
Practice Address - Street 1:208 N MEADOW ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4027
Practice Address - Country:US
Practice Address - Phone:607-272-0006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012117-1111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition