Provider Demographics
NPI:1164543203
Name:PEERY, DERECK A (DO)
Entity Type:Individual
Prefix:DR
First Name:DERECK
Middle Name:A
Last Name:PEERY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 10TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-4025
Mailing Address - Country:US
Mailing Address - Phone:580-223-7200
Mailing Address - Fax:580-223-7207
Practice Address - Street 1:915 10TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-4025
Practice Address - Country:US
Practice Address - Phone:580-223-7200
Practice Address - Fax:580-223-7207
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4546207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK700279OtherINDIVIDUAL PTAN
OK200124470AMedicaid
P00442554OtherRAILROAD MEDICARE
OKOK700279Medicare PIN
243727010Medicare PIN