Provider Demographics
NPI:1477510030
Name:FICKENSCHER, DEREK A (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:A
Last Name:FICKENSCHER
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 1:6700 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1525
Mailing Address - Country:US
Mailing Address - Phone:913-693-7198
Mailing Address - Fax:913-409-3317
Practice Address - Street 1:6700 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1525
Practice Address - Country:US
Practice Address - Phone:913-693-7198
Practice Address - Fax:877-409-3317
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002008817207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205876204Medicaid
H27439Medicare UPIN
MO205876204Medicaid
MO015011878Medicare PIN
MO930120592Medicare PIN