Provider Demographics
NPI:1346338894
Name:OLDHAM, DEREK ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:ALEXANDER
Last Name:OLDHAM
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 1:18077 RIVER RD STE 104A
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-8311
Mailing Address - Country:US
Mailing Address - Phone:317-674-0208
Mailing Address - Fax:317-674-0210
Practice Address - Street 1:18077 RIVER RD STE 104A
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-8311
Practice Address - Country:US
Practice Address - Phone:317-674-0208
Practice Address - Fax:317-674-0210
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059574A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000665052OtherANTHEM - FMC
IN000000622151OtherANTHEM
IN000000693155OtherANTHEM - FPA
IN200946890Medicaid
INP00770326 RR MCRMedicare PIN
IN000000622151OtherANTHEM
INM400017066Medicare PIN