Healthcare Provider Details

I. General information

NPI: 1780024703
Provider Name (Legal Business Name): RENEE DEROSA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2013
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 STATE ROUTE 37
NEW FAIRFIELD CT
06812-4034
US

IV. Provider business mailing address

96 STATE ROUTE 37
NEW FAIRFIELD CT
06812-4034
US

V. Phone/Fax

Practice location:
  • Phone: 203-746-6000
  • Fax: 203-746-0155
Mailing address:
  • Phone: 203-746-6000
  • Fax: 203-746-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number56373
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: