Provider Demographics
NPI:1114212578
Name:DERENNE, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:DERENNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 555191
Mailing Address - Street 2:
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5191
Mailing Address - Country:US
Mailing Address - Phone:760-763-1639
Mailing Address - Fax:
Practice Address - Street 1:200 MERCY CIRCLE
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5191
Practice Address - Country:US
Practice Address - Phone:760-725-1288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA01012524112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program