Provider Demographics
NPI:1437454097
Name:DERSHAM, TODD LEWIS (DC)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:LEWIS
Last Name:DERSHAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 BRALEY HILL RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02770-1917
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 BRALEY HILL RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02770-1917
Practice Address - Country:US
Practice Address - Phone:607-329-4036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1993111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor