Provider Demographics
NPI:1790763779
Name:DEROCHE, CHRISTOPHER THOMAS (DPM)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:THOMAS
Last Name:DEROCHE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 COUNTRY RD HH
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467
Mailing Address - Country:US
Mailing Address - Phone:715-344-9500
Mailing Address - Fax:715-344-9501
Practice Address - Street 1:2020 COUNTRY RD HH
Practice Address - Street 2:
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467
Practice Address - Country:US
Practice Address - Phone:715-344-9500
Practice Address - Fax:715-344-9501
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI703-025213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43220000Medicaid
WIP00437506OtherPALMETTO MEDICARE
WIU50471Medicare UPIN