Provider Demographics
NPI:1689790115
Name:DEROSA, DAVID P (DC)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:P
Last Name:DEROSA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:857 N MAIN STREET EXT STE 4
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2465
Mailing Address - Country:US
Mailing Address - Phone:203-284-9200
Mailing Address - Fax:
Practice Address - Street 1:950 YALE AVE
Practice Address - Street 2:UNIT 32
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1858
Practice Address - Country:US
Practice Address - Phone:203-284-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001390111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor