Provider Demographics
NPI:1659785806
Name:BLACKSON, DERICK
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:
Last Name:BLACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 10TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-2720
Mailing Address - Country:US
Mailing Address - Phone:702-396-2988
Mailing Address - Fax:510-281-6883
Practice Address - Street 1:3674 N RANCHO DR
Practice Address - Street 2:101
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3110
Practice Address - Country:US
Practice Address - Phone:702-396-2988
Practice Address - Fax:510-281-6883
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1114270832Medicaid