Provider Demographics
NPI:1285741199
Name:DESRAVINES, MARIE-JEANNE (MD)
Entity type:Individual
Prefix:
First Name:MARIE-JEANNE
Middle Name:
Last Name:DESRAVINES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1228
Mailing Address - Country:US
Mailing Address - Phone:315-598-4715
Mailing Address - Fax:315-598-4733
Practice Address - Street 1:522 S 4TH ST
Practice Address - Street 2:SUITE 500
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-2946
Practice Address - Country:US
Practice Address - Phone:315-598-4740
Practice Address - Fax:315-598-4719
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221962207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH43037Medicare UPIN
NYCC7098Medicare ID - Type Unspecified