Provider Demographics
NPI:1023718525
Name:FORD, DERON DERMAR I (CNP)
Entity type:Individual
Prefix:
First Name:DERON
Middle Name:DERMAR
Last Name:FORD
Suffix:I
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E OVILLA RD # 1A147
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-2479
Mailing Address - Country:US
Mailing Address - Phone:601-218-7593
Mailing Address - Fax:
Practice Address - Street 1:13737 NOEL RD STE 1400
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-2004
Practice Address - Country:US
Practice Address - Phone:954-939-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1112214363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner