Provider Demographics
NPI:1194083790
Name:JOHN J DEGOVANN DPM PC
Entity type:Organization
Organization Name:JOHN J DEGOVANN DPM PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:SANDY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:215-487-0475
Mailing Address - Street 1:5735 RIDGE AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1747
Mailing Address - Country:US
Mailing Address - Phone:215-487-0475
Mailing Address - Fax:215-487-0171
Practice Address - Street 1:5735 RIDGE AVE STE 203
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1747
Practice Address - Country:US
Practice Address - Phone:215-487-0475
Practice Address - Fax:215-487-0171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC001467L261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADE144778Medicare PIN