Provider Demographics
NPI:1467541755
Name:DESILVA, DERRICK M JR (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:M
Last Name:DESILVA
Suffix:JR
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 1:629 AMBOY AVE
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-3579
Mailing Address - Country:US
Mailing Address - Phone:732-738-8801
Mailing Address - Fax:732-738-8802
Practice Address - Street 1:629 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-3579
Practice Address - Country:US
Practice Address - Phone:732-738-8801
Practice Address - Fax:732-738-8802
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA51400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC56947Medicare UPIN