Provider Demographics
NPI:1073332847
Name:DECONNO, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DECONNO
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 1:200 DUTCH MEADOWS LANE
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302
Mailing Address - Country:US
Mailing Address - Phone:518-344-7634
Mailing Address - Fax:
Practice Address - Street 1:200 DUTCH MEADOWS LANE
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302
Practice Address - Country:US
Practice Address - Phone:518-344-7634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006734156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician