Provider Demographics
NPI:1972584266
Name:DECESARE, MARK W (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:DECESARE
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 1:572 ULSTER AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-1924
Mailing Address - Country:US
Mailing Address - Phone:845-339-6000
Mailing Address - Fax:845-339-6065
Practice Address - Street 1:572 ULSTER AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-1924
Practice Address - Country:US
Practice Address - Phone:845-339-6000
Practice Address - Fax:845-339-6065
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX004697111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYGHI5803085OtherGROUP HEALTH INSURANCE
T53053Medicare UPIN
NYGHI5803085OtherGROUP HEALTH INSURANCE