Provider Demographics
NPI:1427082908
Name:DEASIS, ANSELMO (MD)
Entity type:Individual
Prefix:
First Name:ANSELMO
Middle Name:
Last Name:DEASIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:14903-1303
Mailing Address - Country:US
Mailing Address - Phone:607-734-9539
Mailing Address - Fax:607-734-6293
Practice Address - Street 1:7433 STATE ROUTE 54
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14981
Practice Address - Country:US
Practice Address - Phone:607-776-9198
Practice Address - Fax:607-776-9199
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184984207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01267674Medicaid
NY01267674Medicaid
NYAA1240Medicare PIN