Provider Demographics
NPI:1649290024
Name:DEROSA, MARY CATHERINE (MD)
Entity type:Individual
Prefix:DR
First Name:MARY CATHERINE
Middle Name:
Last Name:DEROSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:148 WEST RIVER STREET
Mailing Address - Street 2:SUITE 8
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02904
Mailing Address - Country:US
Mailing Address - Phone:401-606-3000
Mailing Address - Fax:401-331-8110
Practice Address - Street 1:148 WEST RIVER STREET
Practice Address - Street 2:SUITE 8
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2609
Practice Address - Country:US
Practice Address - Phone:401-606-3000
Practice Address - Fax:401-331-8110
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD7443207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIDO1690Medicare UPIN