Provider Demographics
NPI:1043577448
Name:SANDERSON, DERRICK J
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:J
Last Name:SANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4199 GATEWAY BLVD STE 3500
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-7909
Mailing Address - Country:US
Mailing Address - Phone:812-858-5990
Mailing Address - Fax:812-858-5955
Practice Address - Street 1:4199 GATEWAY BLVD STE 3500
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-7909
Practice Address - Country:US
Practice Address - Phone:812-858-5950
Practice Address - Fax:812-858-5955
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY283330207V00000X
IN02005887A207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300038901Medicaid
KY7100666260Medicaid