Provider Demographics
NPI:1053677831
Name:BROERING, DEREK LEE (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:LEE
Last Name:BROERING
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 1:3535 SOUTHERN BLVD.
Mailing Address - Street 2:
Mailing Address - City:KETTERNG
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1221
Mailing Address - Country:US
Mailing Address - Phone:937-395-8839
Mailing Address - Fax:937-395-8387
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-384-6800
Practice Address - Fax:937-384-6938
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-06
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.122640207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0099105Medicaid
OH0099105Medicaid