Provider Demographics
NPI:1508942897
Name:KANE, DEREK DOUGLAS (MD MS)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:DOUGLAS
Last Name:KANE
Suffix:
Gender:M
Credentials:MD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:301 N. 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501
Mailing Address - Country:US
Mailing Address - Phone:701-877-2040
Mailing Address - Fax:701-639-2465
Practice Address - Street 1:310 N 10TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4516
Practice Address - Country:US
Practice Address - Phone:701-877-2040
Practice Address - Fax:701-639-2465
Is Sole Proprietor?:No
Enumeration Date:2006-10-29
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48821-020208600000X
ND11265208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery