Provider Demographics
NPI:1922118652
Name:DESIRE, NATHANAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:NATHANAEL
Middle Name:
Last Name:DESIRE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 STATION CT
Mailing Address - Street 2:BLDG A SUITE 1
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-2453
Mailing Address - Country:US
Mailing Address - Phone:631-803-8247
Mailing Address - Fax:631-803-8251
Practice Address - Street 1:1 STATION CT
Practice Address - Street 2:BLDG A SUITE 1
Practice Address - City:BELLPORT
Practice Address - State:NY
Practice Address - Zip Code:11713-2453
Practice Address - Country:US
Practice Address - Phone:631-803-8247
Practice Address - Fax:631-803-8251
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY216602207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02502298Medicaid
NYH98837Medicare UPIN
NY02502298Medicaid