Provider Demographics
NPI:1356352652
Name:DEGENHART, JOHN P (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:DEGENHART
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1749 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201
Mailing Address - Country:US
Mailing Address - Phone:570-454-2474
Mailing Address - Fax:570-454-0097
Practice Address - Street 1:1749 E BROAD ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201
Practice Address - Country:US
Practice Address - Phone:570-454-2474
Practice Address - Fax:570-454-0097
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002134L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008908800001Medicaid
PA404709SUHMedicare PIN
PA0008908800001Medicaid