Provider Demographics
NPI:1699969022
Name:C. THOMAS DEROCHE, DPM, LLC
Entity type:Organization
Organization Name:C. THOMAS DEROCHE, DPM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DEROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:715-344-9500
Mailing Address - Street 1:2020 COUNTY RD HH
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467
Mailing Address - Country:US
Mailing Address - Phone:715-344-9500
Mailing Address - Fax:715-344-9501
Practice Address - Street 1:2020 COUNTY RD HH
Practice Address - Street 2:
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467
Practice Address - Country:US
Practice Address - Phone:715-344-9500
Practice Address - Fax:715-344-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI703-025213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43220000Medicaid
WI000015161Medicare PIN
WI7045620001Medicare PIN
WI43220000Medicaid
WI000015151Medicare PIN
WI000015172Medicare PIN