Provider Demographics
NPI:1790771939
Name:DERIENZO, DAVID J (MSPT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:DERIENZO
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4609 EASY ST
Mailing Address - Street 2:
Mailing Address - City:WEST MIFFLIN
Mailing Address - State:PA
Mailing Address - Zip Code:15122-1966
Mailing Address - Country:US
Mailing Address - Phone:412-462-1191
Mailing Address - Fax:412-462-1182
Practice Address - Street 1:6321 LIBRARY RD
Practice Address - Street 2:
Practice Address - City:SOUTH PARK
Practice Address - State:PA
Practice Address - Zip Code:15129-8502
Practice Address - Country:US
Practice Address - Phone:412-833-1986
Practice Address - Fax:412-833-3255
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008610L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016644440004Medicaid
PA0016644440004Medicaid