Basic Information
| Provider Information | |||||||||
| NPI: | 1689054348 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEREZIL | ||||||||
| FirstName: | MICHAL-ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 293 NW PEACOCK BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349862222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723359600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 293 NW PEACOCK BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349862222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723359600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2015 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME151337 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 295136 | NY | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RE0101X | ME151337 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.