Provider Demographics
NPI:1902827496
Name:DEROSE, DEBORAH ANN (DPM)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:ANN
Last Name:DEROSE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 OLD POST RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-8403
Mailing Address - Country:US
Mailing Address - Phone:203-259-4229
Mailing Address - Fax:203-255-4743
Practice Address - Street 1:880 OLD POST RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-8403
Practice Address - Country:US
Practice Address - Phone:203-259-4229
Practice Address - Fax:203-255-4743
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000304213ES0000X, 213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT22828Medicare UPIN