Provider Demographics
NPI:1861492266
Name:DEGENNARO, LOUIS PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:PATRICK
Last Name:DEGENNARO
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 1:940 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510-1007
Mailing Address - Country:US
Mailing Address - Phone:570-346-7900
Mailing Address - Fax:570-963-5060
Practice Address - Street 1:940 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1007
Practice Address - Country:US
Practice Address - Phone:570-346-7900
Practice Address - Fax:570-963-5060
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD010124E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009356960002Medicaid
PA0009356960002Medicaid
PAB33376Medicare UPIN