Provider Demographics
NPI:1962474437
Name:DEMETREE, JOHN WILLIAM (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WILLIAM
Last Name:DEMETREE
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 1:1312 RIVERVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-1257
Mailing Address - Country:US
Mailing Address - Phone:941-792-2007
Mailing Address - Fax:941-792-2007
Practice Address - Street 1:1312 RIVERVIEW CIR
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-1257
Practice Address - Country:US
Practice Address - Phone:941-792-2007
Practice Address - Fax:941-792-2007
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0033525207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL406073299OtherRAILROAD MEDICARE
D58781Medicare UPIN
FL79419Medicare ID - Type Unspecified