Provider Demographics
NPI:1417968538
Name:UMPHLETT, DERRICK CLIFTON (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:CLIFTON
Last Name:UMPHLETT
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 1:645 E MISSOURI AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1351
Mailing Address - Country:US
Mailing Address - Phone:602-262-8917
Mailing Address - Fax:602-262-8890
Practice Address - Street 1:2400 S AVENUE A
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7170
Practice Address - Country:US
Practice Address - Phone:928-344-2000
Practice Address - Fax:928-336-7430
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35861207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ125213Medicaid
I62199Medicare UPIN
AZZ67863Medicare PIN
AZ125213Medicaid
AZZ143272Medicare PIN
AZP00930301Medicare PIN