Provider Demographics
NPI:1487885836
Name:DERIS, AMY (MD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:DERIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:DAVEZAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1936 MAGAZINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70130-5016
Mailing Address - Country:US
Mailing Address - Phone:504-529-5558
Mailing Address - Fax:
Practice Address - Street 1:2000 MAGAZINE ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70130-5018
Practice Address - Country:US
Practice Address - Phone:504-529-5558
Practice Address - Fax:504-529-8840
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115114207Q00000X
MA257326207Q00000X
LA303232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2438727Medicaid