1366514309 NPI number — KEYDRON DWANE DEROSA OD DOCTOR OF OPTOMET

Table of content: KEYDRON DWANE DEROSA OD DOCTOR OF OPTOMET (NPI 1366514309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366514309 NPI number — KEYDRON DWANE DEROSA OD DOCTOR OF OPTOMET

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEROSA
Provider First Name:
KEYDRON
Provider Middle Name:
DWANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD DOCTOR OF OPTOMET
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:
1366514309
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6599 WEST MIDDLETOWN ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44406-9417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-702-8855
Provider Business Mailing Address Fax Number:
330-702-8855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 NORTH HERMITAGE ROAD
Provider Second Line Business Practice Location Address:
WALMART VISION CENTER
Provider Business Practice Location Address City Name:
HERMITAGE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-346-5950
Provider Business Practice Location Address Fax Number:
724-342-6246
Provider Enumeration Date:
11/14/2006

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: 152W00000X , with the licence number:  4976P , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 3165T405 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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