Provider Demographics
NPI:1851473227
Name:BLYTHE, DERRICK ROY (DC)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:ROY
Last Name:BLYTHE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-2031
Mailing Address - Country:US
Mailing Address - Phone:662-728-7414
Mailing Address - Fax:662-728-4163
Practice Address - Street 1:413 N 2ND ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-2031
Practice Address - Country:US
Practice Address - Phone:662-728-7414
Practice Address - Fax:662-728-4163
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS885111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSU47118Medicare UPIN