Provider Demographics
NPI:1811963978
Name:DERIAN, EDIE L (MD)
Entity type:Individual
Prefix:
First Name:EDIE
Middle Name:L
Last Name:DERIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 PORTLAND AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3022
Mailing Address - Country:US
Mailing Address - Phone:585-922-4200
Mailing Address - Fax:585-922-4922
Practice Address - Street 1:1415 PORTLAND AVE STE 400
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3022
Practice Address - Country:US
Practice Address - Phone:585-922-4200
Practice Address - Fax:585-922-4922
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281646207VG0400X
OH35-095609207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001882980Medicaid
F36689Medicare UPIN
OHH045040Medicare PIN
PA054423Medicare ID - Type Unspecified