Provider Demographics
NPI:1851779607
Name:DERUSSO, STEPHANIE JOAN (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:JOAN
Last Name:DERUSSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:SCARFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6730
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85246-6730
Mailing Address - Country:US
Mailing Address - Phone:480-821-3600
Mailing Address - Fax:480-857-2667
Practice Address - Street 1:1634 S PRIEST DR STE 101
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-6499
Practice Address - Country:US
Practice Address - Phone:480-821-3600
Practice Address - Fax:480-345-2003
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ67318207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ577776Medicaid