Provider Demographics
NPI:1629395496
Name:DEROSA, VINCENT A (MD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:A
Last Name:DEROSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2652 WIDDY BOSTICK RD
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-9111
Mailing Address - Country:US
Mailing Address - Phone:716-483-0355
Mailing Address - Fax:
Practice Address - Street 1:2652 WIDDY BOSTWICK LANE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-9111
Practice Address - Country:US
Practice Address - Phone:716-483-0355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116552207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY35011BMedicare PIN