Provider Demographics
NPI:1497724421
Name:DECERCE, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DECERCE
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 1:107 EDWARDS RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:STARKE
Mailing Address - State:FL
Mailing Address - Zip Code:32091-3959
Mailing Address - Country:US
Mailing Address - Phone:904-368-8111
Mailing Address - Fax:904-368-8103
Practice Address - Street 1:107 EDWARDS RD
Practice Address - Street 2:SUITE F
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-3959
Practice Address - Country:US
Practice Address - Phone:904-368-8111
Practice Address - Fax:904-368-8103
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME685992084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2620120-00Medicaid
GA000912315AMedicaid
GA000912315AMedicaid
GA202I139930Medicare PIN
FL2620120-00Medicaid