Provider Demographics
NPI:1104367218
Name:ENGLER, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:ENGLER
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 1:1012 MAVOR ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-2848
Mailing Address - Country:US
Mailing Address - Phone:937-360-7642
Mailing Address - Fax:
Practice Address - Street 1:1012 MAVOR ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-2848
Practice Address - Country:US
Practice Address - Phone:937-360-7642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1204486261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0208810Medicaid
OH1204486OtherDODD CONTRACT NUMBER