Provider Demographics
NPI:1851799183
Name:DEROUX, STEPHEN
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:DEROUX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6419
Practice Address - Country:US
Practice Address - Phone:718-668-0620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180374207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY180374OtherLICENSE