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NPI Code Detail

MEDICARE: MARTIN A DERUSHA DO

MEDICARE: MARTIN A DERUSHA DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207P00000XEmergency Medicine PhysicianK0454TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1H0101698OTHERTXDPS

General Provider Information

NPI Number : 1922046507
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARTIN A DERUSHA DO
Provider Business Mailing Address
First Line : 1506 PENNSYLVANIA AVE
Second Line :
City : FORT WORTH
State : TX
Zip : 76104-2027
Country : US
Telephone Number : 817-882-0984
Fax Number : 817-882-9978
Provider Business Practice Location Address
First Line : 1506 PENNSYLVANIA AVE
Second Line :
City : FORT WORTH
State : TX
Zip : 76104-2027
Country : US
Telephone Number : 817-882-0984
Fax Number : 817-882-9978
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/03/2006
Last Update Date : 03/07/2023

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Directions to “ MARTIN A DERUSHA DO” Practice Location

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