Provider Demographics
NPI:1720388143
Name:DESIDERIO, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DESIDERIO
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 1:1752 MERRIAM DR
Mailing Address - Street 2:SUITE 2001
Mailing Address - City:MARTINSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08836-2378
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MADISON AVE
Practice Address - Street 2:SUITE 2001
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6136
Practice Address - Country:US
Practice Address - Phone:973-682-2136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09518300207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease