Provider Demographics
NPI:1477532299
Name:IPSEN, DEREK FOSTER (DO)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:FOSTER
Last Name:IPSEN
Suffix:
Gender:M
Credentials:DO
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Other - Credentials:
Mailing Address - Street 1:1 JARRETT WHITE RD
Mailing Address - Street 2:TRIPLER ARMY MEDICAL CENTER ATTN: MCHK-QS
Mailing Address - City:TRIPLER AMC
Mailing Address - State:HI
Mailing Address - Zip Code:96859-5001
Mailing Address - Country:US
Mailing Address - Phone:808-433-2460
Mailing Address - Fax:808-433-1558
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:TRIPLER ARMY MEDICAL CENTER
Practice Address - City:TRIPLER AMC
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-2460
Practice Address - Fax:808-433-1558
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2021-06-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2001004848207X00000X
IDO-1368207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1477532299Medicaid
MO1477532299Medicaid
MO500410085Medicare PIN