Provider Demographics
NPI:1235428921
Name:HERVERT, JOHN CHARLES (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:HERVERT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 S SR 15A STE 100
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-7817
Mailing Address - Country:US
Mailing Address - Phone:386-774-0016
Mailing Address - Fax:386-774-0606
Practice Address - Street 1:1590 S SR 15A STE 100
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-7817
Practice Address - Country:US
Practice Address - Phone:386-774-0016
Practice Address - Fax:386-774-0606
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS18043207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200416870AMedicaid
OK311373YM2YOtherMEDICARE