Provider Demographics
NPI:1942512231
Name:RAYSOR, DERRICK LAVAR (IDC)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:LAVAR
Last Name:RAYSOR
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 1:10088 KIT FOX PKWY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32222-4188
Mailing Address - Country:US
Mailing Address - Phone:904-686-6040
Mailing Address - Fax:
Practice Address - Street 1:2104 MASSEY AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32228
Practice Address - Country:US
Practice Address - Phone:904-270-4233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman