Provider Demographics
NPI:1922046507
Name:DERUSHA, MARTIN A (DO)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:A
Last Name:DERUSHA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2027
Mailing Address - Country:US
Mailing Address - Phone:817-882-0984
Mailing Address - Fax:817-882-9978
Practice Address - Street 1:1506 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2027
Practice Address - Country:US
Practice Address - Phone:817-882-0984
Practice Address - Fax:817-882-9978
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0454207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH0101698OtherDPS
TXH0101698OtherDPS
TXH0101698OtherDPS
TX8G3569Medicare ID - Type Unspecified
TX612085Medicare PIN