Provider Demographics
NPI:1063714178
Name:JOSE J DERGAN P. A
Entity type:Organization
Organization Name:JOSE J DERGAN P. A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:
Authorized Official - Last Name:DERGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-599-1970
Mailing Address - Street 1:8249 NW 36TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6673
Mailing Address - Country:US
Mailing Address - Phone:305-599-1970
Mailing Address - Fax:305-599-1971
Practice Address - Street 1:8249 NW 36TH ST STE 100
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6673
Practice Address - Country:US
Practice Address - Phone:305-599-1970
Practice Address - Fax:305-599-1971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4206103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73524Medicare PIN