Healthcare Provider Details

I. General information

NPI: 1558368761
Provider Name (Legal Business Name): STEPHANIE A. DEVERICK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43309 US HIGHWAY 19 N
TARPON SPRINGS FL
34689-6221
US

IV. Provider business mailing address

PO BOX 5002
TARPON SPRINGS FL
34688-5002
US

V. Phone/Fax

Practice location:
  • Phone: 727-943-3116
  • Fax:
Mailing address:
  • Phone: 727-943-3116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME22306
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: