Provider Demographics
NPI:1184260887
Name:DERIVOIS, JEAN MOISE
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:MOISE
Last Name:DERIVOIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10541 SW 224TH TER
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33190-1391
Mailing Address - Country:US
Mailing Address - Phone:786-223-3163
Mailing Address - Fax:
Practice Address - Street 1:2780 SW 37TH AVE
Practice Address - Street 2:
Practice Address - City:COCONUT GROVE
Practice Address - State:FL
Practice Address - Zip Code:33133-2740
Practice Address - Country:US
Practice Address - Phone:305-640-0112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator