Provider Demographics
NPI:1841280047
Name:DERASKA, DONALD JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:JOHN
Last Name:DERASKA
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 1:92 MONTVALE AVE STE 3675
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3625
Mailing Address - Country:US
Mailing Address - Phone:781-438-1800
Mailing Address - Fax:781-438-1822
Practice Address - Street 1:92 MONTVALE AVE STE 3675
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3625
Practice Address - Country:US
Practice Address - Phone:781-438-1800
Practice Address - Fax:781-438-1822
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73990207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA724164OtherTUFTS HEALTH PLAN
MAJ13217OtherBCBS MA
MA3098311Medicaid
MA3098311Medicaid
MAF43228Medicare PIN
F43228Medicare UPIN