Basic Information
| Provider Information | |||||||||
| NPI: | 1003143975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESMERY | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1428 OLD FORD RD | ||||||||
| Address2: | |||||||||
| City: | NEW PALTZ | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125612660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452557758 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1428 OLD FORD RD | ||||||||
| Address2: | |||||||||
| City: | NEW PALTZ | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125612660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452557758 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2009 | ||||||||
| LastUpdateDate: | 11/12/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 093164-1 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | MD93164 | 01 | NY | NONE | OTHER |