Provider Demographics
NPI:1407945827
Name:DERRICK, MELODY JOY (MD)
Entity Type:Individual
Prefix:DR
First Name:MELODY
Middle Name:JOY
Last Name:DERRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MELODY
Other - Middle Name:JOY
Other - Last Name:DERRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-260-0600
Mailing Address - Fax:630-260-1370
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-260-0600
Practice Address - Fax:630-260-1370
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114979207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00386296OtherRR MEDICARE (INDIVIDUAL)
IL036114979Medicaid
ILP00386296OtherRR MEDICARE (INDIVIDUAL)
IL036114979Medicaid