Provider Demographics
NPI:1760463525
Name:DERBY, JAMES A (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:DERBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 RUCKEL DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1782
Mailing Address - Country:US
Mailing Address - Phone:850-496-3096
Mailing Address - Fax:
Practice Address - Street 1:2190 HIGHWAY 85 N
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1045
Practice Address - Country:US
Practice Address - Phone:850-678-4181
Practice Address - Fax:850-729-9418
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80573207P00000X, 207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL059185372OtherBCBS AL
AL059185483OtherBCBS AL
FL51635OtherBC/BS FL
FL97861OtherBCBS FL
FL259858200Medicaid
AL059185483OtherBCBS AL
AL059185372OtherBCBS AL
FL97861OtherBCBS FL
FL259858200Medicaid
FL51635OtherBC/BS FL