Provider Demographics
NPI:1083935084
Name:DEROSA, IVY (DO)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:DEROSA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 PHEASANT RUN
Mailing Address - Street 2:STE 123
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-3413
Mailing Address - Country:US
Mailing Address - Phone:215-702-8600
Mailing Address - Fax:215-633-3480
Practice Address - Street 1:104 PHEASANT RUN
Practice Address - Street 2:SUITE 123
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-3439
Practice Address - Country:US
Practice Address - Phone:215-702-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015851207N00000X, 207N00000X
PAOT013797207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology