Provider Demographics
NPI:1770589194
Name:DEROSA, MICHAEL A (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:DEROSA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3694 STARRS CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9514
Mailing Address - Country:US
Mailing Address - Phone:330-702-1310
Mailing Address - Fax:330-702-1344
Practice Address - Street 1:3694 STARRS CENTRE DR
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9514
Practice Address - Country:US
Practice Address - Phone:330-702-1310
Practice Address - Fax:330-702-1344
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-B028-D207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2409834Medicaid
H09592Medicare UPIN
OH4108131Medicare ID - Type Unspecified