Provider Demographics
NPI:1659628253
Name:DERRICKSON, ROBERT PAUL I
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:PAUL
Last Name:DERRICKSON
Suffix:I
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ROBERT
Other - Middle Name:PAUL
Other - Last Name:DERRICKSON
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:108 MT PLEASANT RD
Mailing Address - Street 2:
Mailing Address - City:BELLE VERNON
Mailing Address - State:PA
Mailing Address - Zip Code:15012-3331
Mailing Address - Country:US
Mailing Address - Phone:724-989-8262
Mailing Address - Fax:724-929-4957
Practice Address - Street 1:108 MT PLEASANT RD
Practice Address - Street 2:
Practice Address - City:BELLE VERNON
Practice Address - State:PA
Practice Address - Zip Code:15012-3331
Practice Address - Country:US
Practice Address - Phone:724-989-8262
Practice Address - Fax:724-929-4957
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA000560E208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation