Provider Demographics
NPI:1831497569
Name:DEROSIA, DAVID C (LMT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:DEROSIA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2143 NE BROADWAY ST STE 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1512
Mailing Address - Country:US
Mailing Address - Phone:971-303-8367
Mailing Address - Fax:
Practice Address - Street 1:2143 NE BROADWAY ST STE 1
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1512
Practice Address - Country:US
Practice Address - Phone:971-303-8367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-03
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16541225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist