Provider Demographics
NPI:1659696771
Name:DERLETH, PHILIP JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:JOHN
Last Name:DERLETH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 VALLEY BROOK DR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-9377
Mailing Address - Country:US
Mailing Address - Phone:585-598-3535
Mailing Address - Fax:
Practice Address - Street 1:1387 FAIRPORT RD
Practice Address - Street 2:SUITE 640
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-2003
Practice Address - Country:US
Practice Address - Phone:585-598-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program