Provider Demographics
NPI:1114047917
Name:PURCELL, DERK D (MD)
Entity Type:Individual
Prefix:DR
First Name:DERK
Middle Name:D
Last Name:PURCELL
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:PO BOX 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3404
Mailing Address - Fax:
Practice Address - Street 1:1101 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-6919
Practice Address - Country:US
Practice Address - Phone:415-600-0800
Practice Address - Fax:415-447-6335
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA902772085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1114047917Medicaid
CABF779WMedicare PIN
CABF779YMedicare PIN
CABF779TMedicare PIN
CABF779ZMedicare PIN
CA1114047917Medicaid