Provider Demographics
NPI:1285623173
Name:DECRESCENZO, GARY JOHN (DPM)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:JOHN
Last Name:DECRESCENZO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 E 56TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4002
Mailing Address - Country:US
Mailing Address - Phone:718-765-4844
Mailing Address - Fax:516-565-0317
Practice Address - Street 1:1560 E 56TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4002
Practice Address - Country:US
Practice Address - Phone:718-765-4844
Practice Address - Fax:516-565-0317
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005333213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01735244Medicaid
NYP76851Medicare ID - Type UnspecifiedBCBC MEDICARE
NY01735244Medicaid
U65049Medicare UPIN