Provider Demographics
NPI:1972539153
Name:DESPERITO, ELISE (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:
Last Name:DESPERITO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 WEST 168TH STREET
Mailing Address - Street 2:COLUMBIA PRESBYTERIAN RADIOLOGY MC 28
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032
Mailing Address - Country:US
Mailing Address - Phone:212-305-1948
Mailing Address - Fax:212-305-5777
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-305-9335
Practice Address - Fax:212-305-8636
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21033512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW35021OtherMEDICARE GROUP #
NY1467560854OtherNPI GROUP#
NY02186203OtherMEDICAID GROUP #
NY01892819Medicaid
NY01892819Medicaid
NY615851Medicare ID - Type Unspecified