Provider Demographics
NPI:1568499283
Name:DEROSA, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:DEROSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:12639 OLD TESSON RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2786
Mailing Address - Country:US
Mailing Address - Phone:314-849-0311
Mailing Address - Fax:314-849-4423
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 101A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-569-2751
Practice Address - Fax:314-569-2986
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR1F40207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO139343OtherHEALTHLINK
MO112121OtherBLUE CROSS BLUE SHIELD
MO203028006Medicaid
MO4333410OtherAETNA
MO203028006Medicaid
MO139343OtherHEALTHLINK