Provider Demographics
NPI:1265934913
Name:TRENT, DERRICK (LAC)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:TRENT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 RIVERSIDE DR APT 21C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-7230
Mailing Address - Country:US
Mailing Address - Phone:212-419-4904
Mailing Address - Fax:
Practice Address - Street 1:626 RIVERSIDE DR APT 21C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-7230
Practice Address - Country:US
Practice Address - Phone:212-419-4904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006211-1208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine