Provider Demographics
NPI:1386723559
Name:DEROSA, MICHAEL PETER (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PETER
Last Name:DEROSA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1207
Mailing Address - Country:US
Mailing Address - Phone:516-239-5405
Mailing Address - Fax:
Practice Address - Street 1:208 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1207
Practice Address - Country:US
Practice Address - Phone:516-239-5405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3982111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX2473100Medicare ID - Type Unspecified