Provider Demographics
NPI:1194032748
Name:DEBOER, DEREK LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:LEE
Last Name:DEBOER
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 1:1550 TOMCAT BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23460-2186
Mailing Address - Country:US
Mailing Address - Phone:757-953-3778
Mailing Address - Fax:
Practice Address - Street 1:1550 TOMCAT BLVD STE 150
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23460-2186
Practice Address - Country:US
Practice Address - Phone:757-953-3778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-02
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101250168208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice