Provider Demographics
NPI:1417139130
Name:LANIER, DEREK (MD MPH)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:LANIER
Suffix:
Gender:M
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 W 8TH ST APT 52
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3730
Mailing Address - Country:US
Mailing Address - Phone:248-842-4421
Mailing Address - Fax:
Practice Address - Street 1:8450 BROWER LAKE RD NE
Practice Address - Street 2:APT/SUITE
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9346
Practice Address - Country:US
Practice Address - Phone:616-874-1577
Practice Address - Fax:616-874-1577
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057270207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine