Provider Demographics
NPI:1568756351
Name:DEROSA, RAFFAELLA (MD)
Entity Type:Individual
Prefix:DR
First Name:RAFFAELLA
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 1:2817 REILLY ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-5001
Mailing Address - Country:US
Mailing Address - Phone:910-907-8236
Mailing Address - Fax:
Practice Address - Street 1:2817 REILLY ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-5001
Practice Address - Country:US
Practice Address - Phone:910-907-8236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI16588208800000X
NC306408208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicaid