Healthcare Provider Details

I. General information

NPI: 1639812522
Provider Name (Legal Business Name): HEATHER M DEREUS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 5TH AVE N
ST PETERSBURG FL
33713-6701
US

IV. Provider business mailing address

2855 5TH AVE N
ST PETERSBURG FL
33713-6701
US

V. Phone/Fax

Practice location:
  • Phone: 727-323-2727
  • Fax: 727-327-8101
Mailing address:
  • Phone: 727-323-2727
  • Fax: 727-327-8101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME175107
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: