Provider Demographics
NPI:1629160817
Name:DERGAN, JOSE J (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:J
Last Name:DERGAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8249 NW 36TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6673
Mailing Address - Country:US
Mailing Address - Phone:305-599-1970
Mailing Address - Fax:305-599-1971
Practice Address - Street 1:8249 NW 36TH ST STE 102
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6673
Practice Address - Country:US
Practice Address - Phone:305-599-1970
Practice Address - Fax:305-599-1971
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 004206103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65-0167578OtherTAX IDENTIFICATION
FL210099100Medicaid
FL73524Medicare ID - Type Unspecified
FL210099100Medicaid