Provider Demographics
NPI:1902377914
Name:CROSS, DEREK ALLAN
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:ALLAN
Last Name:CROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 HARVEST DR
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3671
Mailing Address - Country:US
Mailing Address - Phone:330-593-8727
Mailing Address - Fax:
Practice Address - Street 1:474 HARVEST DR
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3671
Practice Address - Country:US
Practice Address - Phone:330-593-8727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer