Provider Demographics
NPI:1922166867
Name:DUFFIELD, DERRICK R (M D)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:R
Last Name:DUFFIELD
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-3737
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:105 THORNHILL DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1548
Practice Address - Country:US
Practice Address - Phone:601-261-3737
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15467207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121060Medicaid
LA1030945Medicaid
LA1030945Medicaid
MSP00815520OtherRAILROAD MCARE THRU HCCN
MS302I081478Medicare PIN
MS930003522Medicare PIN
MS00121060Medicaid
MSP00815520OtherRAILROAD MCARE THRU HCCN