Provider Demographics
NPI:1558380451
Name:DEROSE, MICHAEL STUART (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STUART
Last Name:DEROSE
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 1:1360 BEVERLY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3643
Mailing Address - Country:US
Mailing Address - Phone:703-893-6388
Mailing Address - Fax:703-893-0770
Practice Address - Street 1:1360 BEVERLY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3643
Practice Address - Country:US
Practice Address - Phone:703-893-6388
Practice Address - Fax:703-893-0770
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001434111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA809811CO6Medicare ID - Type Unspecified