Provider Demographics
NPI:1366491953
Name:FYFE, DEREK A (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:A
Last Name:FYFE
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 1:2835 BRANDYWINE RD
Mailing Address - Street 2:300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341
Mailing Address - Country:US
Mailing Address - Phone:770-488-9202
Mailing Address - Fax:678-547-1499
Practice Address - Street 1:1405 CLIFTON RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322
Practice Address - Country:US
Practice Address - Phone:404-256-2593
Practice Address - Fax:678-547-1494
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0391032080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00633553AMedicaid
D17492Medicare UPIN
GA00633553AMedicaid