Provider Demographics
NPI:1275828717
Name:DERRICK, MICHAEL IAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:IAN
Last Name:DERRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1272 GARRISON DR
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-2598
Mailing Address - Country:US
Mailing Address - Phone:615-893-4480
Mailing Address - Fax:615-895-6212
Practice Address - Street 1:1272 GARRISON DR
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-2598
Practice Address - Country:US
Practice Address - Phone:615-893-4480
Practice Address - Fax:615-895-6212
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-402052080P0201X
MO20170235192080P0201X
TNMD659692080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology