Provider Demographics
NPI:1578573614
Name:DERRICK, BRIAN C (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:C
Last Name:DERRICK
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 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:509-663-8711
Mailing Address - Fax:
Practice Address - Street 1:933 RED APPLE RD STE B
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-3370
Practice Address - Country:US
Practice Address - Phone:509-665-6212
Practice Address - Fax:509-667-3370
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60021759207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1578573614Medicaid
WAP01409880OtherRR MEDICARE WVH
WA338901OtherWVH LNI
WA1578573614Medicaid
WA8947913OtherL&I CRIME VICTIMS
WA1578573614Medicaid
WAG8921336Medicare PIN