Provider Demographics
NPI:1013228469
Name:DERRICK, KRISTINA (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:
Last Name:DERRICK
Suffix:
Gender:F
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:SUNY DOWNSTATE MEDICAL CENTER
Mailing Address - Street 2:450 CLARKSON AVENUE
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203
Mailing Address - Country:US
Mailing Address - Phone:718-270-1229
Mailing Address - Fax:718-270-2794
Practice Address - Street 1:PARAGON SKIN
Practice Address - Street 2:214 COMMONS WAY, BUILDING B
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755
Practice Address - Country:US
Practice Address - Phone:732-234-7546
Practice Address - Fax:732-234-5202
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ106526208000000X
NY2845372080P0205X, 390200000X
NJ25MA10534400207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program