Provider Demographics
NPI:1538368592
Name:DEROSE, LOUIS R (MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:R
Last Name:DEROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 KS HWY 264
Mailing Address - Street 2:
Mailing Address - City:LARNED
Mailing Address - State:KS
Mailing Address - Zip Code:67550-5353
Mailing Address - Country:US
Mailing Address - Phone:620-285-4507
Mailing Address - Fax:620-285-4509
Practice Address - Street 1:1301 KS HWY 264
Practice Address - Street 2:
Practice Address - City:LARNED
Practice Address - State:KS
Practice Address - Zip Code:67550-5353
Practice Address - Country:US
Practice Address - Phone:620-285-4507
Practice Address - Fax:620-285-4509
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
KS08-003112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No103T00000XBehavioral Health & Social Service ProvidersPsychologist