Provider Demographics
NPI:1336158542
Name:DESHRAGE, KARL A (MD)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:A
Last Name:DESHRAGE
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 1:365 EAST MAIN ST
Mailing Address - Street 2:SOUTH BROOKHAVEN HEALTH CENTER WEST
Mailing Address - City:PATCHOQUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772
Mailing Address - Country:US
Mailing Address - Phone:631-854-1307
Mailing Address - Fax:631-854-1310
Practice Address - Street 1:365 EAST MAIN ST
Practice Address - Street 2:SOUTH BROOKHAVEN HEALTH CENTER WEST
Practice Address - City:PATCHOQUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-854-1307
Practice Address - Fax:631-854-1310
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132912207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01769864Medicaid
38F631Medicare ID - Type Unspecified
NY01769864Medicaid