Healthcare Provider Details

I. General information

NPI: 1184744336
Provider Name (Legal Business Name): DEBORSHI ROY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8241 ROCHESTER AVE 130
RANCHO CUCAMONGA CA
91730-0713
US

IV. Provider business mailing address

PO BOX 77365
CORONA CA
92877-0112
US

V. Phone/Fax

Practice location:
  • Phone: 909-466-8400
  • Fax:
Mailing address:
  • Phone: 909-466-8400
  • Fax: 909-880-1102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberC54320
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2286241
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: