Provider Demographics
NPI:1548232853
Name:DEROSA, MADDALENA (MD)
Entity Type:Individual
Prefix:
First Name:MADDALENA
Middle Name:
Last Name:DEROSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 FAIRGROVE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NC
Mailing Address - Zip Code:28658-8531
Mailing Address - Country:US
Mailing Address - Phone:828-468-3980
Mailing Address - Fax:828-464-2845
Practice Address - Street 1:1915 FAIRGROVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NC
Practice Address - Zip Code:28658-8531
Practice Address - Country:US
Practice Address - Phone:828-468-3980
Practice Address - Fax:828-464-2845
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT40093207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT110009644Medicare ID - Type Unspecified