Provider Demographics
NPI:1780024703
Name:DEROSA, RENEE (MD)
Entity Type:Individual
Prefix:
First Name:RENEE
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 1:96 STATE ROUTE 37
Mailing Address - Street 2:
Mailing Address - City:NEW FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06812-4034
Mailing Address - Country:US
Mailing Address - Phone:203-746-6000
Mailing Address - Fax:203-746-0155
Practice Address - Street 1:96 STATE ROUTE 37
Practice Address - Street 2:
Practice Address - City:NEW FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06812-4034
Practice Address - Country:US
Practice Address - Phone:203-746-6000
Practice Address - Fax:203-746-0155
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT56373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine