MEDICARE: DR. JOHN DEREK DENIGRIS IV M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	ME142769	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ME142769	OTHER	FL	FL LICENSE
2	036.165455	OTHER	IL	IL LICENSE

General Provider Information

NPI Number	:	1174987259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN DEREK DENIGRIS IV M.D.

Provider Business Mailing Address
First Line	:	2590 HEALING WAY STE 220
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33543-5496
Country	:	US
Telephone Number	:	847-381-8899
Fax Number	:

Provider Business Practice Location Address
First Line	:	2590 HEALING WAY STE 220
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33543-5496
Country	:	US
Telephone Number	:	847-381-8899
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2016
Last Update Date	:	09/25/2023

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