Provider Demographics
NPI:1821453911
Name:GOODING, DEREK LEE (IDC)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:LEE
Last Name:GOODING
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 482 BOX 2738
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96362-2799
Mailing Address - Country:US
Mailing Address - Phone:804-869-7017
Mailing Address - Fax:
Practice Address - Street 1:PSC 482 BOX 2738
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96362-2799
Practice Address - Country:US
Practice Address - Phone:804-869-7017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman