Provider Demographics
NPI:1780822841
Name:MATHIS, DERRICK JOHN (ALFA)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:JOHN
Last Name:MATHIS
Suffix:
Gender:M
Credentials:ALFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9827 SUDLEY MANOR DR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-6232
Mailing Address - Country:US
Mailing Address - Phone:703-530-7751
Mailing Address - Fax:
Practice Address - Street 1:9827 SUDLEY MANOR DR
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-6232
Practice Address - Country:US
Practice Address - Phone:703-530-7751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1706000192376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator