Provider Demographics
NPI:1639260847
Name:TOOTH, DERRICK S (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:S
Last Name:TOOTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9 PLEASANT STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:OAKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04963
Mailing Address - Country:US
Mailing Address - Phone:207-465-2700
Mailing Address - Fax:207-465-2300
Practice Address - Street 1:1053 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:ME
Practice Address - Zip Code:04351-3403
Practice Address - Country:US
Practice Address - Phone:207-622-6319
Practice Address - Fax:207-622-6654
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2012-12-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ME014663208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME255890099Medicaid
ME030440OtherANTHEM
1041053OtherAETNA
ME255890099Medicaid
1041053OtherAETNA