Provider Demographics
NPI:1275524662
Name:DEROSA, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:DEROSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2347 LENORA CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3232
Mailing Address - Country:US
Mailing Address - Phone:770-979-2020
Mailing Address - Fax:770-978-3321
Practice Address - Street 1:2347 LENORA CHURCH RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3232
Practice Address - Country:US
Practice Address - Phone:770-979-2020
Practice Address - Fax:770-978-3321
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033954207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00475098AMedicaid
GA18BDCFVMedicare ID - Type UnspecifiedMEDICARE ID
GAA63943Medicare UPIN