Provider Demographics
NPI:1205949013
Name:VAN DERWOOD, JOHN GAYLE (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GAYLE
Last Name:VAN DERWOOD
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7101 US HIGHWAY 90
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-9512
Mailing Address - Country:US
Mailing Address - Phone:251-625-8211
Mailing Address - Fax:251-625-8219
Practice Address - Street 1:7101 US HIGHWAY 90
Practice Address - Street 2:SUITE 202
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-9512
Practice Address - Country:US
Practice Address - Phone:251-625-8211
Practice Address - Fax:251-625-8219
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2014-12-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS14230207Q00000X
AL11539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-04616OtherBLUE CROSS OF AL
AL051558401Medicaid
C72872Medicare UPIN
AL051558401Medicare PIN