Provider Demographics
NPI:1073703641
Name:DWAYNE R DEPRY DO INC
Entity Type:Organization
Organization Name:DWAYNE R DEPRY DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEPRY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:559-261-2799
Mailing Address - Street 1:1221 E SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720
Mailing Address - Country:US
Mailing Address - Phone:559-261-2799
Mailing Address - Fax:559-261-2796
Practice Address - Street 1:1221 E SPRUCE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720
Practice Address - Country:US
Practice Address - Phone:559-261-2799
Practice Address - Fax:559-261-2796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A94032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI68086Medicare UPIN