Provider Demographics
NPI:1821283409
Name:DEBORAH A. DEROSE, D.P.M.
Entity Type:Organization
Organization Name:DEBORAH A. DEROSE, D.P.M.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPOUSE
Authorized Official - Prefix:
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:SAUL
Authorized Official - Last Name:PRUSOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-255-9975
Mailing Address - Street 1:880 OLD POST RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-8403
Mailing Address - Country:US
Mailing Address - Phone:203-255-9975
Mailing Address - Fax:
Practice Address - Street 1:880 OLD POST RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-8403
Practice Address - Country:US
Practice Address - Phone:203-255-9975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000304213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT22823Medicare UPIN
CTT22828Medicare UPIN