Provider Demographics
NPI:1982657516
Name:DEROO, MARK WALTER (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WALTER
Last Name:DEROO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:23450 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-8702
Mailing Address - Country:US
Mailing Address - Phone:913-764-7788
Mailing Address - Fax:913-764-6088
Practice Address - Street 1:23450 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-8702
Practice Address - Country:US
Practice Address - Phone:913-764-7788
Practice Address - Fax:913-764-6088
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS0427012208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100293370EMedicaid
E05841Medicare UPIN
KS0337921DMedicare ID - Type Unspecified