Provider Demographics
NPI:1568860708
Name:HAIRSTON, DERICK L II (CPT)
Entity Type:Individual
Prefix:MR
First Name:DERICK
Middle Name:L
Last Name:HAIRSTON
Suffix:II
Gender:M
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 LARCHMONT AVE
Mailing Address - Street 2:BLOODWORKS
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-2839
Mailing Address - Country:US
Mailing Address - Phone:202-910-2252
Mailing Address - Fax:
Practice Address - Street 1:612 LARCHMONT AVE
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-2839
Practice Address - Country:US
Practice Address - Phone:202-910-2252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-19
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor