| Doctor Name: | IVY DEROSA |
| NPI Number: | 1083935084 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | D.O. |
| License Number: | OT013797 |
| Business Practice Address: | 50 N Perry St Pontiac, MI - 483422217 |
| Business Phone Number: | 2483485000 |
| Business Fax Number: | |
| Mailing Address: | 662 Purdy St, Apt 318 BIRMINGHAM |
| State: | MI |
| Postal Code: | 480091731 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 06/14/2010 |
| NPI Last Update Date: | 07/01/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | OT013797 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | PA |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |