Provider Demographics
NPI:1699824326
Name:DEHARDE, JOHN ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:DEHARDE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1056
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37011-1056
Mailing Address - Country:US
Mailing Address - Phone:931-680-3035
Mailing Address - Fax:
Practice Address - Street 1:1880 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-2018
Practice Address - Country:US
Practice Address - Phone:931-680-3035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD1192152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
47939OtherDAVIS VISION
45397OtherSPECTERA
TN0105045OtherBC BS OF TN
T81675Medicare UPIN
47939OtherDAVIS VISION