Provider Demographics
NPI:1508493982
Name:FOSTER, DEREK (DO)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:FOSTER
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 1:24 FRANK LLOYD WRIGHT DR
Mailing Address - Street 2:SUITE J2000
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:IHA WATERFORD PRIMARY CARE
Practice Address - Street 2:4400 HIGHLAND RD
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328
Practice Address - Country:US
Practice Address - Phone:248-618-6000
Practice Address - Fax:248-619-6951
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5101026945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program