Provider Demographics
NPI:1235134214
Name:DEROSA, ANTHONY JOHN (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOHN
Last Name:DEROSA
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 1:860 OMNI BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4430
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:757-232-8875
Practice Address - Street 1:860 OMNI BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4430
Practice Address - Country:US
Practice Address - Phone:757-223-5321
Practice Address - Fax:757-223-7271
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101056744207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI10057OtherOPTIMA
VI242760OtherANTHEM BC/BS
NC890588LOtherNC MEDICAID
VA6304991Medicaid
VA180035098OtherRR MEDICARE
G38724Medicare UPIN
NC890588LOtherNC MEDICAID