Provider Demographics
NPI:1750945218
Name:DECESARE, CRAIG
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:DECESARE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-6221
Mailing Address - Country:US
Mailing Address - Phone:516-798-9605
Mailing Address - Fax:516-798-9373
Practice Address - Street 1:5700 MERRICK RD
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-6221
Practice Address - Country:US
Practice Address - Phone:516-798-9605
Practice Address - Fax:516-798-9373
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044179208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty