Provider Demographics
NPI:1477533768
Name:DEROSA, JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:DEROSA
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 1:2585 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1642
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:205 MARION PIKE
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638-3165
Practice Address - Country:US
Practice Address - Phone:740-532-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1329207V00000X
OH34004625207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000178447OtherANTHEM BC
OH0715417Medicaid
KY64698939Medicaid
OH001709561OtherMT.STATE
WV0092290000Medicaid
WV001790560OtherMT. STATE
OH0715417Medicaid
WV0092290000Medicaid
KY64698939Medicaid
WV2015163Medicare PIN