Provider Demographics
NPI:1992736672
Name:DEGRAW, JOHN R (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:DEGRAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHNNIE
Other - Middle Name:R
Other - Last Name:DEGRAW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5915 W GULF TO LAKE HWY
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-7565
Mailing Address - Country:US
Mailing Address - Phone:352-794-3872
Mailing Address - Fax:352-794-3876
Practice Address - Street 1:5915 W GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-7565
Practice Address - Country:US
Practice Address - Phone:352-794-3872
Practice Address - Fax:352-794-3876
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL108911261QR1300X
FLME0048978207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02120AOtherBCBS
FL208262765OtherTAX ID
FL6450130001OtherDMERC
FLP00473712OtherRAILROAD MEDICARE
FL274574700Medicaid
FL02120BMedicare ID - Type Unspecified
FL02120AOtherBCBS
FL6450130001Medicare NSC
FL02120UMedicare PIN
FL6450130001OtherDMERC
FLD67068Medicare UPIN