Provider Demographics
NPI:1386304459
Name:DERIZE, ALLAN GASNER
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:GASNER
Last Name:DERIZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 MARIETTA LN
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-5143
Mailing Address - Country:US
Mailing Address - Phone:352-357-4147
Mailing Address - Fax:
Practice Address - Street 1:863 MARIETTA LN
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-5143
Practice Address - Country:US
Practice Address - Phone:352-357-4147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31681225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant