Provider Demographics
NPI:1386629921
Name:DEROSE, JOSEPH J (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:J
Last Name:DEROSE
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MMC. CARDIOTHORACIC SURGERY 3400 BAINBRIDGE AVE.
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2490
Mailing Address - Country:US
Mailing Address - Phone:718-920-4799
Mailing Address - Fax:718-653-2237
Practice Address - Street 1:MMC. CARDIOTHORACIC SURGERY 1575 BLONDELL AVE.
Practice Address - Street 2:SUITE 125
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-920-4799
Practice Address - Fax:718-653-2237
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2028061208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02149333Medicaid
NY5003E1Medicare ID - Type Unspecified
NY02149333Medicaid