Provider Demographics
NPI:1629137658
Name:BARRY P. DERAN, M.D., INC.
Entity Type:Organization
Organization Name:BARRY P. DERAN, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:DERAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-897-7611
Mailing Address - Street 1:5705 MONCLOVA RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1875
Mailing Address - Country:US
Mailing Address - Phone:419-897-7611
Mailing Address - Fax:419-897-7615
Practice Address - Street 1:5705 MONCLOVA RD
Practice Address - Street 2:SUITE 204
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1875
Practice Address - Country:US
Practice Address - Phone:419-897-7611
Practice Address - Fax:419-897-7615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2634224Medicaid
OHBA9318681Medicare PIN