Provider Demographics
NPI:1093976151
Name:DEROSA, AUSTIN BANNING (MD)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:BANNING
Last Name:DEROSA
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:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 PARK CENTRAL DR
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-6688
Practice Address - Country:US
Practice Address - Phone:303-265-3940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-21
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0053887208800000X, 208800000X
SC35896208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology