Provider Demographics
NPI:1912902578
Name:DERR, CRAIG ALAN (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:ALAN
Last Name:DERR
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 70888
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19176-5888
Mailing Address - Country:US
Mailing Address - Phone:610-988-8446
Mailing Address - Fax:610-988-4242
Practice Address - Street 1:6TH AVE AND SPRUCE ST
Practice Address - Street 2:
Practice Address - City:W. READING
Practice Address - State:PA
Practice Address - Zip Code:19611
Practice Address - Country:US
Practice Address - Phone:610-988-5455
Practice Address - Fax:610-988-4242
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024286E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA114746402Medicaid
PA113270Medicare ID - Type Unspecified
PA114746402Medicaid