Basic Information
| Provider Information | |||||||||
| NPI: | 1679516595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEROSE | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 PROVIDENCE RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212862976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 7098667954 | ||||||||
| Practice Location | |||||||||
| Address1: | 698 BALTIMORE PIKE | ||||||||
| Address2: | |||||||||
| City: | BEL AIR | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210144264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108790044 | ||||||||
| FaxNumber: | 4108936871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 08/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA0948 | MD | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | KZ41 / 687259-01 | 01 | MD | BC / BS OF MD | OTHER | S186 / 0029 | 01 | MD | BLUECHOICE | OTHER | 161268900 | 05 | MD | MEDICAID |