Individual
DR. MICHAEL J DEROSA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
621 S NEW BALLAS RD, SUITE 101A, SAINT LOUIS, MO 63141-8232
(314) 569-2751
(314) 569-2986
Mailing address
12639 OLD TESSON RD, SUITE 115, SAINT LOUIS, MO 63128-2786
(314) 849-0311
(314) 849-4423
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
R1F40
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
112121
BLUE CROSS BLUE SHIELD
MO
01
—
139343
HEALTHLINK
MO
05
—
203028006
—
MO
01
—
4333410
AETNA
MO
Enumeration date
06/27/2006
Last updated
07/17/2019
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