Provider Demographics
NPI:1609876606
Name:ANDERSON, DERRICK (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2301 US HIGHWAY 74 W
Practice Address - Street 2:
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170-7554
Practice Address - Country:US
Practice Address - Phone:704-994-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-02612207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026494200Medicaid
NE10026451700Medicaid
04012OtherBCBS
NE47082189713Medicaid
NE10025024300Medicaid
NE1002466400Medicaid
NE10024946900Medicaid
NE10025024400Medicaid
NE10026476700Medicaid
NE10026494200Medicaid
NE10026476700Medicaid
NE10026451700Medicaid