Provider Demographics
NPI:1427036375
Name:DERDERIAN, SARKIS (DO)
Entity Type:Individual
Prefix:
First Name:SARKIS
Middle Name:
Last Name:DERDERIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 HARDEN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-1014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1875 HARDEN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1014
Practice Address - Country:US
Practice Address - Phone:803-256-0464
Practice Address - Fax:803-254-5121
Is Sole Proprietor?:No
Enumeration Date:2006-01-02
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC384207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC003846Medicaid
SCB950905253Medicare PIN
SC003846Medicaid