Individual
DR. JOHN P. DERVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
100 NICOLLS RD # T-16030, STONY BROOK, NY 11794-0001
(631) 444-3655
(631) 444-1054
Mailing address
100 NICOLLS RD # T-16030, STONY BROOK, NY 11794-8160
(631) 444-3655
(631) 444-1054
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
Primary
166207
NY
207RI0011X
Interventional Cardiology Physician
166207
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00964109
—
NV
Enumeration date
07/05/2006
Last updated
01/25/2022
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