Provider Demographics
NPI:1376514950
Name:DEROSA, JULIE ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:ANN
Last Name:DEROSA
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 1:10090 GEORGIA STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307
Mailing Address - Country:US
Mailing Address - Phone:219-472-4077
Mailing Address - Fax:219-267-1720
Practice Address - Street 1:10090 GEORGIA STREET, SUITE #3
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307
Practice Address - Country:US
Practice Address - Phone:219-472-4077
Practice Address - Fax:219-267-1720
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049022A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01049022AOtherINDIANA LICENSE
IN01049022BOtherCSR
IN200540460Medicaid
INFD1598765OtherDEA