Provider Demographics
NPI:1679516595
Name:DEROSE, JOSEPH L (OD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:L
Last Name:DEROSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 PROVIDENCE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-2976
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:709-866-7954
Practice Address - Street 1:698 BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4264
Practice Address - Country:US
Practice Address - Phone:410-879-0044
Practice Address - Fax:410-893-6871
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0948152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKZ41 / 687259-01OtherBC / BS OF MD
MDS186 / 0029OtherBLUECHOICE
MD161268900Medicaid
293L / 031YMedicare ID - Type Unspecified
MDKZ41 / 687259-01OtherBC / BS OF MD