Provider Demographics
NPI:1871524439
Name:DERVAN, JOHN P (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:DERVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:100 NICOLLS RD # T-16030
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8160
Mailing Address - Country:US
Mailing Address - Phone:631-444-3655
Mailing Address - Fax:631-444-1054
Practice Address - Street 1:100 NICOLLS RD # T-16030
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-3655
Practice Address - Fax:631-444-1054
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY166207207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV00964109Medicaid
NY75D061Medicare ID - Type Unspecified
NV00964109Medicaid