Provider Demographics
NPI:1881397396
Name:MIMBA, DERICK
Entity type:Individual
Prefix:
First Name:DERICK
Middle Name:
Last Name:MIMBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14333 ROSETREE CT
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-1939
Mailing Address - Country:US
Mailing Address - Phone:410-710-7481
Mailing Address - Fax:
Practice Address - Street 1:14333 ROSETREE CT
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906-1939
Practice Address - Country:US
Practice Address - Phone:410-710-7481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker