Provider Demographics
NPI:1942325915
Name:DEROSA, LIBERATUS ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:LIBERATUS
Middle Name:ANTHONY
Last Name:DEROSA
Suffix:
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 1:546 HEAVITREE LN
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-1023
Mailing Address - Country:US
Mailing Address - Phone:443-623-2148
Mailing Address - Fax:410-987-1224
Practice Address - Street 1:2101 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4908
Practice Address - Country:US
Practice Address - Phone:301-816-6660
Practice Address - Fax:301-816-6308
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD39147207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDK679H246Medicare ID - Type UnspecifiedKAISER PERMANENTE
MDF42177Medicare UPIN