Provider Demographics
NPI:1407832579
Name:CLUNIS, DERRICK OLIVER (MD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:OLIVER
Last Name:CLUNIS
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:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:13535 NEMOURS PKWY
Practice Address - Street 2:NEMOURS CHILDRENS HOSPITAL
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7402
Practice Address - Country:US
Practice Address - Phone:407-567-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78560208000000X, 208M00000X
MO2021012259208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257755100Medicaid
FL257755100Medicaid
FL257755100Medicaid