OrganizationMartin A. Derusha, Jr., D.O,, P.A.(Martin Derusha, Jr., D.O.)Family MedicineAllopathic & Osteopathic PhysiciansPractice Address1510 Pennsylvania Ave, Fort Worth, TX 76104-2027(817) 882-0984PECOS EnrollmentBased on the most recent information from CMS, provider Martin A. Derusha, Jr., D.O,, P.A. does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records 3 days ago.Profile DetailsProvider ID1497801211Provider TypeOrganizationFull NameMartin A. Derusha, Jr., D.O,, P.A.Other NameMartin Derusha, Jr., D.O.SubpartNoEnumeration Date1/26/2007Last Updated8/22/2020Contact InformationPractice LocationPractice Address1510 Pennsylvania Ave, Fort Worth, TX 76104-2027Phone(817) 882-0984FaxUnlisted FaxMailing LocationMailing Address1510 Pennsylvania Ave, Fort Worth, TX 76104-2027Phone(817) 882-0984FaxUnlisted FaxAuthorized OfficialNameDerusha, Martin Allyn (Owner)Phone(817) 882-0984Provider TaxonomiesCodeDescriptionLicenseCode207Q00000XPrimaryDescriptionFamily MedicineAllopathic & Osteopathic PhysiciansLicenseK0454Texas