Provider Demographics
NPI:1184116873
Name:PYNE, DEREK E (DO)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:E
Last Name:PYNE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3074 N US 31 S
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4533
Mailing Address - Country:US
Mailing Address - Phone:231-929-1234
Mailing Address - Fax:231-935-0984
Practice Address - Street 1:3074 N US 31 S
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4533
Practice Address - Country:US
Practice Address - Phone:231-929-1234
Practice Address - Fax:231-935-0984
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101023845207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101025413OtherLICENSE 2021