Basic Information
| Provider Information | |||||||||
| NPI: | 1841388485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DECESARE | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 E BROWN ST | ||||||||
| Address2: | |||||||||
| City: | EAST STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183013006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708976272 | ||||||||
| FaxNumber: | 5708390893 | ||||||||
| Practice Location | |||||||||
| Address1: | 716 DELAWARE AVENUE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183510358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708976272 | ||||||||
| FaxNumber: | 5708390893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS002690L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | DE041920 | 01 | PA | BLUE SHIELD/BLUE CROSS | OTHER | 503825 | 01 | PA | US HEALTHCARE/AETNA | OTHER | 14843 | 01 | PA | GEISENGERS | OTHER |