Provider Demographics
NPI:1396005518
Name:DEROSA, THOMAS A (DPT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:DEROSA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 OLD COUNTRY RD STE A2
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2059
Mailing Address - Country:US
Mailing Address - Phone:631-284-9258
Mailing Address - Fax:631-284-9260
Practice Address - Street 1:1149 OLD COUNTRY RD STE A2
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2059
Practice Address - Country:US
Practice Address - Phone:631-284-9258
Practice Address - Fax:631-284-9260
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist