Provider Demographics
NPI:1104997683
Name:DEOROSAN, VERRETTA (MD)
Entity type:Individual
Prefix:
First Name:VERRETTA
Middle Name:
Last Name:DEOROSAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11502 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-6522
Mailing Address - Country:US
Mailing Address - Phone:323-779-2800
Mailing Address - Fax:323-754-4014
Practice Address - Street 1:11502 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-6522
Practice Address - Country:US
Practice Address - Phone:323-779-2800
Practice Address - Fax:323-754-4014
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73639207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG736390Medicaid
CAG73639Medicare ID - Type Unspecified
CAF43122Medicare UPIN