Provider Demographics
NPI:1306862719
Name:BRUBAKER, DERICK S (MD)
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:S
Last Name:BRUBAKER
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 1:304 N WATER ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-3374
Mailing Address - Country:US
Mailing Address - Phone:717-735-6808
Mailing Address - Fax:717-945-1587
Practice Address - Street 1:515B HERSHEY AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-5752
Practice Address - Country:US
Practice Address - Phone:717-299-6372
Practice Address - Fax:717-945-1587
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041153207Q00000X
PAMD417531207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8317182Medicaid
WA8317182Medicaid
WAAB32759Medicare ID - Type Unspecified