Provider Demographics
NPI:1063502755
Name:DERESKA, PAUL S (DO)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:S
Last Name:DERESKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 BASS POND DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-1937
Mailing Address - Country:US
Mailing Address - Phone:469-600-5681
Mailing Address - Fax:
Practice Address - Street 1:3308 PRESTON RD
Practice Address - Street 2:STE. 350-283
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-7453
Practice Address - Country:US
Practice Address - Phone:214-471-5975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5013207L00000X
VA0102201821207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010242193Medicaid
TX8DL180OtherBLUE CROSS BLUE SHIELD
TX305164102Medicaid
TX302164101Medicaid
TXTXB163466Medicare PIN
TX8DL180OtherBLUE CROSS BLUE SHIELD
VA010242193Medicaid
P00285034Medicare PIN