Provider Demographics
NPI:1881674638
Name:PESA, CARL A (DC)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:A
Last Name:PESA
Suffix:
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 1:1728 BROADWAY
Mailing Address - Street 2:STE 3
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1630
Mailing Address - Country:US
Mailing Address - Phone:516-593-3339
Mailing Address - Fax:516-593-3339
Practice Address - Street 1:1728 BROADWAY
Practice Address - Street 2:STE 3
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1630
Practice Address - Country:US
Practice Address - Phone:516-593-3339
Practice Address - Fax:516-593-3339
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX2992111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1C X17071Medicare PIN