Provider Demographics
NPI:1407290372
Name:PALMER, DEREK S (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:S
Last Name:PALMER
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 1:101 JUDGE TANNER BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7506
Mailing Address - Country:US
Mailing Address - Phone:985-888-8750
Mailing Address - Fax:985-888-8760
Practice Address - Street 1:1707 W CHARLESTON BLVD STE 160
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2354
Practice Address - Country:US
Practice Address - Phone:702-671-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS26665208600000X
LA313121208600000X
LA3221432086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2332171Medicaid
LA322143OtherNORTH OAKS MEDICAL CENTER / PHYSICIAN GROUP