Basic Information
| Provider Information | |||||||||
| NPI: | 1306846589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEJOYA | ||||||||
| FirstName: | GERMAN | ||||||||
| MiddleName: | DY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3024 NEW BERN AVENUE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193507270 | ||||||||
| FaxNumber: | 9193507204 | ||||||||
| Practice Location | |||||||||
| Address1: | 3024 NEW BERN AVENUE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276100000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193507270 | ||||||||
| FaxNumber: | 9193507204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 11/30/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD055492L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 2008-00611 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02213596 | 01 | NY | NY MEDICAL ASSISTANCE | OTHER | 0018741920001 | 05 | PA | MEDICAID | 00025817201 | 01 | NY | UNIVERA | OTHER | 124571 | 01 | PA | UNISON | OTHER | 1521461 | 01 | PA | GATEWAY | OTHER | 2109107 | 01 | PA | AETNA | OTHER | 110241542 | 01 | PA | RR MEDICARE | OTHER | 400014 | 01 | PA | UPMC | OTHER | 193623 | 01 | PA | BLUE SHIELD | OTHER | 2282882 | 01 | OH | OH MEDICAL ASSISTANCE | OTHER | 1047850 | 01 | WV | WEST VIRGINIA WORK COMP | OTHER |