Provider Demographics
NPI:1316127145
Name:DERUSO, WILLIAM ALBERT (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ALBERT
Last Name:DERUSO
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:DEPT LA 21613
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1613
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:800-409-7005
Practice Address - Street 1:2320 BATH ST STE 113
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-4377
Practice Address - Country:US
Practice Address - Phone:805-682-7744
Practice Address - Fax:805-682-3321
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ442122085R0202X
CAA1015782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A101578OtherBS OF CA
AZ617939Medicaid
CA1316127145Medicaid
CA00A101578OtherBS OF CA
CA1316127145Medicaid
AZ617939Medicaid
CAGF672ZMedicare PIN