Provider Demographics
NPI:1265895619
Name:NICKERSON, DEREK WALTER (MD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:WALTER
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5550 CARMEL MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-4853
Mailing Address - Country:US
Mailing Address - Phone:858-943-2540
Mailing Address - Fax:
Practice Address - Street 1:5550 CARMEL MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-4853
Practice Address - Country:US
Practice Address - Phone:858-943-2540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-02
Last Update Date:2025-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA171167207ND0101X, 207ND0101X
SCLL41017207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty