Provider Demographics
NPI:1225747363
Name:DERICK DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:DERICK DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:DERICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-381-8899
Mailing Address - Street 1:10114 GIBSONTON DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-5305
Mailing Address - Country:US
Mailing Address - Phone:847-381-8899
Mailing Address - Fax:
Practice Address - Street 1:10114 GIBSONTON DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-5305
Practice Address - Country:US
Practice Address - Phone:847-381-8899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty