Provider Demographics
NPI:1255588810
Name:DEPERRO, MICHAEL PHILLIP III (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PHILLIP
Last Name:DEPERRO
Suffix:III
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 1:1830 BETHEL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-1809
Mailing Address - Country:US
Mailing Address - Phone:614-940-6607
Mailing Address - Fax:614-429-4948
Practice Address - Street 1:1830 BETHEL RD STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-1809
Practice Address - Country:US
Practice Address - Phone:614-940-6607
Practice Address - Fax:614-429-4948
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-25
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH112600208200000X
OH122373208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH811530392OtherTAX-ID
OH1134573496Medicaid