1396771424 NPI number — DEAN DEROBERTS MD

Table of content: DEAN DEROBERTS MD (NPI 1396771424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396771424 NPI number — DEAN DEROBERTS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEROBERTS
Provider First Name:
DEAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396771424
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4567 CROSSROADS PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVERPOOL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13088-3589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-295-2100
Provider Business Mailing Address Fax Number:
315-295-2125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4900 BROAD RD
Provider Second Line Business Practice Location Address:
STE 2G
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13215-5103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-299-5313
Provider Business Practice Location Address Fax Number:
315-299-5661
Provider Enumeration Date:
06/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  ME95604 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X , with the licence number: 256232 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)