Provider Demographics
NPI:1770689895
Name:DEREGIS, DAVID L (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:DEREGIS
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:ATTENTION: PROVIDER SERVICES VICKY DETRICK
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-887-6323
Mailing Address - Fax:570-887-6324
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:ATTENTION: PROVIDER SERVICES VICKY DETRICK
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-887-6323
Practice Address - Fax:570-887-6324
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35991207R00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000236623OtherBCBS PROVIDER NUMBER
KY35991OtherLICENSE
KY64018898Medicaid
0601358Medicare PIN
000000236623OtherBCBS PROVIDER NUMBER
H28346Medicare UPIN
0600288Medicare PIN