Provider Demographics
NPI:1932959244
Name:DEROUCHIE, MICHAEL A
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:DEROUCHIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 DUANE ST APT 12
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-2363
Mailing Address - Country:US
Mailing Address - Phone:315-957-9701
Mailing Address - Fax:
Practice Address - Street 1:125 FINNEY BLVD
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1067
Practice Address - Country:US
Practice Address - Phone:518-481-8160
Practice Address - Fax:518-481-8161
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist