Provider Demographics
NPI:1497801211
Name:MARTIN A. DERUSHA, JR., D.O,, P.A.
Entity Type:Organization
Organization Name:MARTIN A. DERUSHA, JR., D.O,, P.A.
Other - Org Name:MARTIN DERUSHA, JR., D.O.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:ALLYN
Authorized Official - Last Name:DERUSHA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:817-882-0984
Mailing Address - Street 1:1510 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2027
Mailing Address - Country:US
Mailing Address - Phone:817-882-0984
Mailing Address - Fax:
Practice Address - Street 1:1510 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2027
Practice Address - Country:US
Practice Address - Phone:817-882-0984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0454207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG47667Medicare UPIN