Provider Demographics
NPI:1831747450
Name:DEGORI, ANTHONY ALEXANDER
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:ALEXANDER
Last Name:DEGORI
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 1:10 NORTHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:FORT SALONGA
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2413
Mailing Address - Country:US
Mailing Address - Phone:631-786-7538
Mailing Address - Fax:
Practice Address - Street 1:10 NORTHFIELD DR
Practice Address - Street 2:
Practice Address - City:FORT SALONGA
Practice Address - State:NY
Practice Address - Zip Code:11768-2413
Practice Address - Country:US
Practice Address - Phone:631-786-7538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225XL0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistLow Vision