Provider Demographics
NPI:1649251174
Name:DERUSSY, PETER KIRK (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:KIRK
Last Name:DERUSSY
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 1:6661 CLYO RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2702
Mailing Address - Country:US
Mailing Address - Phone:937-425-4000
Mailing Address - Fax:937-425-4002
Practice Address - Street 1:2115 LEITER RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-3659
Practice Address - Country:US
Practice Address - Phone:937-384-6800
Practice Address - Fax:937-384-6939
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 076115207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2507184Medicaid
OHDE4143562Medicare PIN
OH4143562Medicare PIN
OH2507184Medicaid
I17622Medicare UPIN