Provider Demographics
NPI:1003809724
Name:DAMIN, DEREK A (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:A
Last Name:DAMIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:163 SOUTH ENGLISH STATION ROAD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-3996
Practice Address - Country:US
Practice Address - Phone:502-882-2063
Practice Address - Fax:502-882-2067
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35810207K00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK093420OtherMEDICARE PTAN
KY64087174Medicaid
KY50005296OtherPASSPORT
KY64087174Medicaid
IN295345OtherHARMONY
KY50005296OtherPASSPORT
KYI16852Medicare UPIN
KY64087174Medicaid