NPIMap

Individual provider Active NPI

John P. Dervan, MD

  • Cardiovascular Disease Physician
  • Stony Brook, NY
National Provider Identifier
1871524439
Registry record updated Jan 25, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Cardiovascular Disease PhysicianTaxonomy code 207RC0000X
License
166207 Issued in NY
Practice address
100 Nicolls Rd # T-16030
Stony Brook, NY 11794-0001
Phone
(631) 444-3655
Fax
(631) 444-1054
NPI assigned
Jul 5, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 25, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Interventional Cardiology Physician 207RI0011X 166207 NY
Cardiovascular Disease Physician 207RC0000X 166207 NY Primary

Addresses

Primary practice location

100 Nicolls Rd # T-16030
Stony Brook, NY 11794-0001

Mailing address

100 Nicolls Rd # T-16030
Stony Brook, NY 11794-8160
Phone (631) 444-3655

Other identifiers 1

IdentifierTypeStateIssuer
00964109MedicaidNV

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20260203000720 NY Practitioner - Cardiovascular Disease (Cardiology) 2365440146 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Cardiovascular Disease (Cardiology)
Education
Saint Louis University School of Medicine, 1976
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

301 E Main St
Bay Shore, NY 11706-8408
Phone (631) 941-2000

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
166207NYMDCardiovascular Disease Physician

Practice roles

OrganizationSpecialtyStatusNew patients
North Suffolk Cardiology Associates Cardiovascular Disease PastSince Jul 7, 2008 Accepting new patients
Stony Brook Internists, University Faculty Practice Corporation Past Accepting new patients
Stony Brook Community Medical, P.C. Cardiovascular Disease Past Accepting new patients
Heart Associates of Long Island PLLC PastSince Aug 9, 2006 Accepting new patients

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152057600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1643068800000",
    "number": "1871524439",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 NICOLLS RD # T-16030",
            "city": "STONY BROOK",
            "state": "NY",
            "postal_code": "117948160",
            "telephone_number": "631-444-3655",
            "fax_number": "631-444-1054"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 NICOLLS RD # T-16030",
            "city": "STONY BROOK",
            "state": "NY",
            "postal_code": "117940001",
            "telephone_number": "631-444-3655",
            "fax_number": "631-444-1054"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DERVAN",
        "first_name": "JOHN",
        "middle_name": "P.",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-05",
        "last_updated": "2022-01-25",
        "certification_date": "2022-01-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207RI0011X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Interventional Cardiology",
            "state": "NY",
            "license": "166207",
            "primary": false
        },
        {
            "code": "207RC0000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": "NY",
            "license": "166207",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00964109",
            "state": "NV"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Stony Brook, NY

Sources for this page

Verify at the official NPI Registry.