Provider Demographics
NPI:1346263779
Name:DEROSE, MARIELAINA S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIELAINA
Middle Name:S
Last Name:DEROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 ENGLE ST
Mailing Address - Street 2:DEPARTMENT OF MEDICINE
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-1808
Mailing Address - Country:US
Mailing Address - Phone:201-894-3000
Mailing Address - Fax:
Practice Address - Street 1:350 ENGLE ST
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-1808
Practice Address - Country:US
Practice Address - Phone:201-894-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06822600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG88338Medicare UPIN