Provider Demographics
NPI:1861459265
Name:DERISO, ANTHONY J II (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:DERISO
Suffix:II
Gender:M
Credentials:MD
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 2381
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-2381
Mailing Address - Country:US
Mailing Address - Phone:419-609-8000
Mailing Address - Fax:419-609-8002
Practice Address - Street 1:1200 PROSPECT ST STE 101
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-3366
Practice Address - Country:US
Practice Address - Phone:419-609-8000
Practice Address - Fax:419-609-8002
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2776208G00000X
OH35064444208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0883469Medicaid
OHDE4032381Medicare PIN
F27453Medicare UPIN
OH0883469Medicaid