MEDICARE: JACK DEROVANESIAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	ME26879	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	78470	OTHER	FL	BC BS FL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073567186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK DEROVANESIAN MD

Provider Business Mailing Address
First Line	:	PO BOX 160448
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33116-0448
Country	:	US
Telephone Number	:	239-262-4519
Fax Number	:	239-262-5672

Provider Business Practice Location Address
First Line	:	6400 DAVIS BLVD STE 103
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34104-5321
Country	:	US
Telephone Number	:	239-775-2300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	05/12/2008

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