Provider Demographics
NPI:1982015020
Name:DESROCHES, BETHANY (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:
Last Name:DESROCHES
Suffix:
Gender:F
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 ESSEX ST STE 403
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-8566
Mailing Address - Country:US
Mailing Address - Phone:551-996-2667
Mailing Address - Fax:
Practice Address - Street 1:360 ESSEX ST STE 403
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-8566
Practice Address - Country:US
Practice Address - Phone:551-996-2667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10050157208600000X
NJ25MA10578000208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBP10050157OtherTEXAS MEDICAL BOARD
NJ25MA10578000OtherNJ MEDICAL LICENSE