Basic Information
| Provider Information | |||||||||
| NPI: | 1316127145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERUSO | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | ALBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 21613 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911851613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492638620 | ||||||||
| FaxNumber: | 8004097005 | ||||||||
| Practice Location | |||||||||
| Address1: | 2320 BATH ST STE 113 | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931054377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056827744 | ||||||||
| FaxNumber: | 8056823321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2007 | ||||||||
| LastUpdateDate: | 10/30/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 44212 | AZ | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | A101578 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00A101578 | 01 | CA | BS OF CA | OTHER | 617939 | 05 | AZ | MEDICAID | 1316127145 | 05 | CA | MEDICAID |