Provider Demographics
NPI:1568774362
Name:ZICKGRAF, DEREK GUY (DO)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:GUY
Last Name:ZICKGRAF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:541-523-4415
Mailing Address - Fax:541-523-2399
Practice Address - Street 1:3175 POCAHONTAS RD
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814
Practice Address - Country:US
Practice Address - Phone:541-523-4415
Practice Address - Fax:541-523-2399
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2017-03-29
Deactivation Date:
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Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO181773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN