Provider Demographics
NPI:1093709610
Name:DESROSIERS, SERGINE (DPM)
Entity Type:Individual
Prefix:
First Name:SERGINE
Middle Name:
Last Name:DESROSIERS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 LENOX RD
Mailing Address - Street 2:BOX1262
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2017
Mailing Address - Country:US
Mailing Address - Phone:718-602-6200
Mailing Address - Fax:
Practice Address - Street 1:613 THROOP AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-2522
Practice Address - Country:US
Practice Address - Phone:718-602-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005664-1207XX0004X
NJMD002675213EP1101X
PASC005652213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8696900Medicaid
PA1964230004Medicaid
PA1964230004Medicaid
NJ8696900Medicaid
PA072797Medicare ID - Type Unspecified
NJ052699Medicare ID - Type Unspecified