Provider Demographics
NPI:1154331478
Name:DERATUS, KARL G (MD)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:G
Last Name:DERATUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:55 WATER ST
Mailing Address - Street 2:2ND FLOOR CRED DEPT
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:169-59 137TH AVE
Practice Address - Street 2:
Practice Address - City:ROCHDALE
Practice Address - State:NY
Practice Address - Zip Code:11434
Practice Address - Country:US
Practice Address - Phone:718-525-5600
Practice Address - Fax:718-559-5285
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY227013207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02425556Medicaid
NY02425556Medicaid