Provider Demographics
NPI:1366514309
Name:DEROSA, KEYDRON DWANE (OD DOCTOR OF OPTOMET)
Entity type:Individual
Prefix:
First Name:KEYDRON
Middle Name:DWANE
Last Name:DEROSA
Suffix:
Gender:M
Credentials:OD DOCTOR OF OPTOMET
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6599 WEST MIDDLETOWN ROAD
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9417
Mailing Address - Country:US
Mailing Address - Phone:330-702-8855
Mailing Address - Fax:330-702-8855
Practice Address - Street 1:1275 NORTH HERMITAGE ROAD
Practice Address - Street 2:WALMART VISION CENTER
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148
Practice Address - Country:US
Practice Address - Phone:724-346-5950
Practice Address - Fax:724-342-6246
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA4976P152W00000X
OH3165T405152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U13205Medicare UPIN