Provider Demographics
NPI:1891873022
Name:TESORO, DEREK ROBERT (DPM)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:ROBERT
Last Name:TESORO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5400 MACKINAW
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-9549
Mailing Address - Country:US
Mailing Address - Phone:989-790-4662
Mailing Address - Fax:989-790-7680
Practice Address - Street 1:5400 MACKINAW
Practice Address - Street 2:SUITE 2100
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-9549
Practice Address - Country:US
Practice Address - Phone:989-790-4662
Practice Address - Fax:989-790-7680
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDT001450213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3173006Medicaid
480019411OtherMEDICARE RAILROAD
4857311150OtherBLUE CROSS
11290415OtherCAQH
MI0M12060Medicare Oscar/Certification
480019411OtherMEDICARE RAILROAD