Provider Demographics
NPI:1720244932
Name:BURGESS, DERRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:
Last Name:BURGESS
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:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0247
Mailing Address - Country:US
Mailing Address - Phone:601-399-6167
Mailing Address - Fax:601-399-6281
Practice Address - Street 1:1002 JEFFERSON ST.
Practice Address - Street 2:SUITE 350
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4306
Practice Address - Country:US
Practice Address - Phone:601-649-5990
Practice Address - Fax:601-399-6281
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45479207X00000X
OH35.099675207X00000X
MS23260207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery