Provider Demographics
NPI:1427538701
Name:DERISIO, VINCENT (DO)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:DERISIO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 612
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-0612
Mailing Address - Country:US
Mailing Address - Phone:513-300-6910
Mailing Address - Fax:
Practice Address - Street 1:42 E LAUREL RD
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1354
Practice Address - Country:US
Practice Address - Phone:513-300-6910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05189300207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology