Provider Demographics
NPI:1831141753
Name:DEROSE, CHRISTOPHER J (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:J
Last Name:DEROSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 KEENE ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8104
Mailing Address - Country:US
Mailing Address - Phone:573-874-2030
Mailing Address - Fax:
Practice Address - Street 1:500 KEENE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8104
Practice Address - Country:US
Practice Address - Phone:573-874-2030
Practice Address - Fax:573-884-5575
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009246152W00000X
MO2006037577152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO314025008Medicaid
MO314025008Medicaid
MO261135236Medicare PIN
ILU80311Medicare UPIN