Provider Demographics
NPI:1215084165
Name:DESIDERIO, MARC RONALD (DC)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:RONALD
Last Name:DESIDERIO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 LEONARDVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-2310
Mailing Address - Country:US
Mailing Address - Phone:732-671-9005
Mailing Address - Fax:732-671-9006
Practice Address - Street 1:9 LEONARDVILLE RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-2310
Practice Address - Country:US
Practice Address - Phone:732-671-9005
Practice Address - Fax:732-671-9006
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00569900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU83502Medicare UPIN
NJ045028Medicare PIN