Provider Demographics
NPI:1407327448
Name:LADEAIROUS, DERRICK (DR)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:LADEAIROUS
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-1902
Mailing Address - Country:US
Mailing Address - Phone:631-974-1849
Mailing Address - Fax:
Practice Address - Street 1:1732 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204
Practice Address - Country:US
Practice Address - Phone:631-974-1849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX013188111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1467755751OtherGROUP NPI