Healthcare Provider Details

I. General information

NPI: 1831198324
Provider Name (Legal Business Name): JOHN M DIVERIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W 89TH AVE SUITE W5
MERRILLVILLE IN
46410-7073
US

IV. Provider business mailing address

333 W 89TH AVE SUITE W5
MERRILLVILLE IN
46410-7073
US

V. Phone/Fax

Practice location:
  • Phone: 219-755-4448
  • Fax: 219-755-4454
Mailing address:
  • Phone: 219-755-4448
  • Fax: 219-755-4454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number01040065A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: