Provider Demographics
NPI:1760787287
Name:DERRICK UMPHLETT MD PC
Entity Type:Organization
Organization Name:DERRICK UMPHLETT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:C
Authorized Official - Last Name:UMPHLETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-609-9300
Mailing Address - Street 1:8970 E RAINTREE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-7300
Mailing Address - Country:US
Mailing Address - Phone:480-609-9300
Mailing Address - Fax:480-609-9350
Practice Address - Street 1:5102 W CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-1703
Practice Address - Country:US
Practice Address - Phone:480-609-9300
Practice Address - Fax:480-609-9350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ684468Medicaid
AZ684468Medicaid
AZDR4067Medicare PIN
AZZ143271Medicare PIN