Healthcare Provider Details

I. General information

NPI: 1407663263
Provider Name (Legal Business Name): DR. ZOREN DEGTYAREV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 327, H STREET
FPO AA
28547
US

IV. Provider business mailing address

CAMP LEJEUNE, BUILDING 327, H STREET
FPO AA
28547
US

V. Phone/Fax

Practice location:
  • Phone: 910-451-6628
  • Fax:
Mailing address:
  • Phone: 910-451-6628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number028022
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: