Provider Demographics
NPI:1699766196
Name:DE HARTER, DAVID JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:DE HARTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:JOHN
Other - Last Name:HARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4811 SW THISTLE TER
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-3948
Mailing Address - Country:US
Mailing Address - Phone:772-971-5111
Mailing Address - Fax:281-337-2611
Practice Address - Street 1:4811 SW THISTLE TER
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-3948
Practice Address - Country:US
Practice Address - Phone:772-971-5111
Practice Address - Fax:281-337-2611
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00712282085R0001X
FLME712282085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32407OtherBCBS
FL252150400Medicaid
FL920004980OtherRAILROAD MEDICARE
FL32407OtherBCBS
FL920004980OtherRAILROAD MEDICARE