Provider Demographics
NPI:1760626519
Name:FANSLER, DERRICK ROTH (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:ROTH
Last Name:FANSLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2222 N NEVADA AVE
Mailing Address - Street 2:SUITE 4007
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6819
Mailing Address - Country:US
Mailing Address - Phone:719-776-8500
Mailing Address - Fax:719-634-1448
Practice Address - Street 1:2222 N NEVADA AVE
Practice Address - Street 2:SUITE 4007
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907
Practice Address - Country:US
Practice Address - Phone:719-776-8500
Practice Address - Fax:719-634-1448
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-23
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO53906207RC0000X
CODR.0053906207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease