Provider Demographics
NPI:1285723189
Name:DEROSA, ANTHONY (PT)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:DEROSA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 ROUTE 25A
Mailing Address - Street 2:SUITE 240
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-8556
Mailing Address - Country:US
Mailing Address - Phone:631-821-5500
Mailing Address - Fax:631-821-5580
Practice Address - Street 1:333 ROUTE 25A
Practice Address - Street 2:SUITE 240
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-8556
Practice Address - Country:US
Practice Address - Phone:631-821-5500
Practice Address - Fax:631-821-5580
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0106762251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ6120Medicare PIN