Provider Demographics
NPI:1164485470
Name:DEAVER, JOHN EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:DEAVER
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 1:7324 GREGORY BLVD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-3945
Mailing Address - Country:US
Mailing Address - Phone:302-465-1959
Mailing Address - Fax:
Practice Address - Street 1:1505 W SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-7059
Practice Address - Country:US
Practice Address - Phone:302-465-1959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010008638207V00000X
DEC1-0010768207V00000X
NY158011207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00826737OtherRAILROAD MEDICARE CB9013
431560263OtherTRICARE WEST
MO1164485470Medicaid
NY01071732Medicaid
MO1164485470Medicaid
MO132680128Medicare PIN
MO132680128Medicare PIN