Provider Demographics
NPI:1619201688
Name:DERCK, CARA E (DO)
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:E
Last Name:DERCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 WESTERN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FINDLAY
Mailing Address - State:OH
Mailing Address - Zip Code:45840-1390
Mailing Address - Country:US
Mailing Address - Phone:419-423-4994
Mailing Address - Fax:419-423-4110
Practice Address - Street 1:1725 WESTERN AVE STE A
Practice Address - Street 2:
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840-1390
Practice Address - Country:US
Practice Address - Phone:419-423-4994
Practice Address - Fax:419-423-4110
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.014037207RG0300X, 207Q00000X
MI5101018178207Q00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH651420OtherMEDICARE-OH
OH0362679Medicaid