Provider Demographics
NPI:1184676272
Name:DERIENZIS, JOHN JOSEPH (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:DERIENZIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-8809
Mailing Address - Country:US
Mailing Address - Phone:828-294-9130
Mailing Address - Fax:828-291-9159
Practice Address - Street 1:2165 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-8809
Practice Address - Country:US
Practice Address - Phone:828-294-9130
Practice Address - Fax:828-291-9159
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7691225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12527OtherBCBS
NC2504058Medicare ID - Type Unspecified