Provider Demographics
NPI:1114274503
Name:BOND, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BOND
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 1:26604 STATE HWY T
Mailing Address - Street 2:
Mailing Address - City:EXCELLO
Mailing Address - State:MO
Mailing Address - Zip Code:65247-2162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 BUTLER ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-1629
Practice Address - Country:US
Practice Address - Phone:660-385-6244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001018647225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist