Provider Demographics
NPI:1588631485
Name:DEROSAS, ANDREA L (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:DEROSAS
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 1:400 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-1207
Mailing Address - Country:US
Mailing Address - Phone:716-816-2515
Mailing Address - Fax:716-816-2066
Practice Address - Street 1:400 FOREST AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-1207
Practice Address - Country:US
Practice Address - Phone:716-816-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223237207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00025948403OtherUNIVERA
NY000526772003OtherBC/BS
NY0411408OtherIHA
NY02282635Medicaid
NY151079BJOtherPREFERRED CARE
NY02282635Medicaid
NY00025948403OtherUNIVERA