Healthcare Provider Details

I. General information

NPI: 1992771158
Provider Name (Legal Business Name): DUANE E. DEIVERT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 BALTIMORE DR
WILKES BARRE PA
18702-7900
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-3034
US

V. Phone/Fax

Practice location:
  • Phone: 570-808-5757
  • Fax: 570-808-5753
Mailing address:
  • Phone: 570-271-6144
  • Fax: 570-271-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOS012660
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberOS012660
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: