Provider Demographics
NPI:1588283063
Name:DEREVA, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:DEREVA
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 1:2845 CASCADE COVE DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-7607
Mailing Address - Country:US
Mailing Address - Phone:214-687-2392
Mailing Address - Fax:214-602-7003
Practice Address - Street 1:2000 GLEN ECHO RD STE 105
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215-2857
Practice Address - Country:US
Practice Address - Phone:214-687-2392
Practice Address - Fax:214-602-7003
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory