Provider Demographics
NPI:1851391296
Name:DESVERREAUX, ROBERT WILLIAM (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:DESVERREAUX
Suffix:
Gender:M
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 759047
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9047
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:2051 WEST ST
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3006
Practice Address - Country:US
Practice Address - Phone:443-603-0758
Practice Address - Fax:443-603-0759
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0047028207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G82693Medicare UPIN
MD495172YWV2Medicare PIN
MD149223YVZMedicare PIN
MD149223ZDDBMedicare PIN