Provider Demographics
NPI:1043425309
Name:DEROSIER, LEO CHRISTOPHER (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:CHRISTOPHER
Last Name:DEROSIER
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 1:2030 FLEISCHMANN RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308
Mailing Address - Country:US
Mailing Address - Phone:850-219-2000
Mailing Address - Fax:850-877-2138
Practice Address - Street 1:2030 FLEISCHMANN RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-219-2000
Practice Address - Fax:850-877-2138
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116517208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051116213OtherBCBS
AL128756Medicaid
AL051116211OtherBCBS
AL128741Medicaid
AL051116208OtherBCBS
AL051116209OtherBCBS
AL128744Medicaid
AL128750Medicaid
MS05683733Medicaid
AL128758Medicaid
AL051116212OtherBCBS
AL128741Medicaid