Provider Demographics
NPI:1841204211
Name:DECASTRO PEGUERO, CLARICIO (MD)
Entity Type:Individual
Prefix:DR
First Name:CLARICIO
Middle Name:
Last Name:DECASTRO PEGUERO
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 1:154 ORANGEBURGH RD
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-7499
Mailing Address - Country:US
Mailing Address - Phone:551-204-2543
Mailing Address - Fax:212-939-2068
Practice Address - Street 1:506 LENOX AVENUE
Practice Address - Street 2:3RD FLOOR MLK BLDG / PAIN MANAGEMENT CLINIC
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-1000
Practice Address - Fax:212-939-2068
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206656207LP2900X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02060277Medicaid
NYH12028Medicare UPIN
NY37B831Medicare ID - Type Unspecified