Provider Demographics
NPI:1407991276
Name:DEROSE, MARY HOWLAND (DC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:HOWLAND
Last Name:DEROSE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2935 SOUTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-3797
Mailing Address - Country:US
Mailing Address - Phone:928-203-4863
Mailing Address - Fax:928-203-4497
Practice Address - Street 1:2935 SOUTHWEST DR
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-3797
Practice Address - Country:US
Practice Address - Phone:928-203-4863
Practice Address - Fax:928-203-4497
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7153111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0934200OtherBCBS
AZAZ0934200OtherBCBS
AZU61555Medicare UPIN