Provider Demographics
NPI:1609127257
Name:BLANCHETTE DESROSIERS, MIREILLE (DPM)
Entity Type:Individual
Prefix:DR
First Name:MIREILLE
Middle Name:
Last Name:BLANCHETTE DESROSIERS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1156 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAINSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07092-2906
Mailing Address - Country:US
Mailing Address - Phone:908-793-8454
Mailing Address - Fax:908-325-0040
Practice Address - Street 1:1156 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAINSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07092-2906
Practice Address - Country:US
Practice Address - Phone:908-793-8454
Practice Address - Fax:908-325-0040
Is Sole Proprietor?:No
Enumeration Date:2012-09-23
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00322700213ES0103X
NYN006610213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery