Provider Demographics
NPI:1790823318
Name:DEROSA, JOSEPH T (PT)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:T
Last Name:DEROSA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1999 NEW RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-1060
Mailing Address - Country:US
Mailing Address - Phone:609-601-6140
Mailing Address - Fax:609-601-6141
Practice Address - Street 1:1999 NEW RD
Practice Address - Street 2:SUITE C
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1060
Practice Address - Country:US
Practice Address - Phone:609-601-6140
Practice Address - Fax:609-601-6141
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2017-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA40872300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ034332USJMedicare ID - Type Unspecified