Provider Demographics
NPI:1659470532
Name:DECAROLIS, PATRICK G
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:G
Last Name:DECAROLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MIDDLE NECK RD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576
Mailing Address - Country:US
Mailing Address - Phone:516-365-2700
Mailing Address - Fax:516-365-2794
Practice Address - Street 1:30 MIDDLE NECK RD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576
Practice Address - Country:US
Practice Address - Phone:516-365-2700
Practice Address - Fax:516-365-2794
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX005595111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX005595OtherLICENSE
NYX005595OtherLICENSE
NYX43671Medicare ID - Type Unspecified