Provider Demographics
NPI:1023035524
Name:DERICKSON, JAMES LYLE (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LYLE
Last Name:DERICKSON
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 1:825 N GRAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-1061
Mailing Address - Country:US
Mailing Address - Phone:520-761-2133
Mailing Address - Fax:520-281-2335
Practice Address - Street 1:1852 N MASTICK WAY
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621
Practice Address - Country:US
Practice Address - Phone:520-281-1550
Practice Address - Fax:520-281-4487
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ266946Medicaid
COA16890Medicare ID - Type Unspecified