Provider Demographics
NPI:1679034011
Name:HALE, DEREK JAMES
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JAMES
Last Name:HALE
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 1:445 BURNINGTREE DR
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3109
Mailing Address - Country:US
Mailing Address - Phone:361-522-7382
Mailing Address - Fax:
Practice Address - Street 1:FC 83 NUMI
Practice Address - Street 2:TROUT AVE
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-694-2876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman