Provider Demographics
NPI:1326486283
Name:KROLL, DEREK GENE (DO)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:GENE
Last Name:KROLL
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 1:1304 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3558
Mailing Address - Country:US
Mailing Address - Phone:309-454-1400
Mailing Address - Fax:
Practice Address - Street 1:500 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2889
Practice Address - Country:US
Practice Address - Phone:281-719-9681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125063639207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125063639OtherILLINOIS STATE LICENSE