Provider Demographics
NPI:1801040894
Name:MARVIN J. DERRICK, M.D. INC.
Entity Type:Organization
Organization Name:MARVIN J. DERRICK, M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-664-9990
Mailing Address - Street 1:PO BOX 22140
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93390-2140
Mailing Address - Country:US
Mailing Address - Phone:661-664-9990
Mailing Address - Fax:
Practice Address - Street 1:500 OLD RIVER RD
Practice Address - Street 2:SUITE 250
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-9504
Practice Address - Country:US
Practice Address - Phone:661-664-9990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG478552086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty