Provider Demographics
NPI:1477181006
Name:ANDERSON, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8915 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-1717
Mailing Address - Country:US
Mailing Address - Phone:214-351-3490
Mailing Address - Fax:
Practice Address - Street 1:120 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-4264
Practice Address - Country:US
Practice Address - Phone:214-351-3490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty