Provider Demographics
NPI:1063562445
Name:DERAMO, DAVID MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:DERAMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:370 GRAND AVE
Mailing Address - Street 2:ENGLEWOOD KNEE & SPORTS MEDICINE,SUITE 100
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4154
Mailing Address - Country:US
Mailing Address - Phone:201-567-5700
Mailing Address - Fax:201-567-8049
Practice Address - Street 1:370 GRAND AVE STE 100
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4109
Practice Address - Country:US
Practice Address - Phone:015-675-7002
Practice Address - Fax:201-567-8049
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08226000207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ123011Medicare PIN