Basic Information
| Provider Information | |||||||||
| NPI: | 1376514950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEROSA | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10090 GEORGIA STREET | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2194724077 | ||||||||
| FaxNumber: | 2192671720 | ||||||||
| Practice Location | |||||||||
| Address1: | 10090 GEORGIA STREET, SUITE #3 | ||||||||
| Address2: | |||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2194724077 | ||||||||
| FaxNumber: | 2192671720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 01/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01049022A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01049022A | 01 | IN | INDIANA LICENSE | OTHER | 01049022B | 01 | IN | CSR | OTHER | 200540460 | 05 | IN | MEDICAID | FD1598765 | 01 | IN | DEA | OTHER |