Provider Demographics
NPI:1295042976
Name:RILEY, DEREK (DO)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:RILEY
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 1:204 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-4566
Mailing Address - Country:US
Mailing Address - Phone:931-363-3514
Mailing Address - Fax:
Practice Address - Street 1:204 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478-4566
Practice Address - Country:US
Practice Address - Phone:931-363-3514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT012646207X00000X
TN2628207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery