Healthcare Provider Details

I. General information

NPI: 1982015020
Provider Name (Legal Business Name): BETHANY DESROCHES MD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 ESSEX ST STE 403
HACKENSACK NJ
07601-8566
US

IV. Provider business mailing address

360 ESSEX ST STE 403
HACKENSACK NJ
07601-8566
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2667
  • Fax:
Mailing address:
  • Phone: 551-996-2667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberBP10050157
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number25MA10578000
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierBP10050157
Identifier TypeOTHER
Identifier StateTX
Identifier IssuerTEXAS MEDICAL BOARD
# 2
Identifier25MA10578000
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerNJ MEDICAL LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: