Provider Demographics
NPI:1972015600
Name:WISTON, DEREK
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:WISTON
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 1:11671 ISLAND LAKES LN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33498-6802
Mailing Address - Country:US
Mailing Address - Phone:561-504-1725
Mailing Address - Fax:
Practice Address - Street 1:21065 POWERLINE RD STE 2A
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-2311
Practice Address - Country:US
Practice Address - Phone:561-883-7800
Practice Address - Fax:561-883-7800
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18829225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist