Provider Demographics
NPI:1982352118
Name:DERODAR, STEVENSON
Entity Type:Individual
Prefix:
First Name:STEVENSON
Middle Name:
Last Name:DERODAR
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 1:765 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-7358
Mailing Address - Country:US
Mailing Address - Phone:718-377-5000
Mailing Address - Fax:
Practice Address - Street 1:765 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-7358
Practice Address - Country:US
Practice Address - Phone:718-377-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008240225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant