Provider Demographics
NPI:1932163409
Name:DERKSEN, JAMES A (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:DERKSEN
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 1:3080 ACKERMAN BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-3658
Mailing Address - Country:US
Mailing Address - Phone:937-534-4201
Mailing Address - Fax:937-291-6941
Practice Address - Street 1:3080 ACKERMAN BLVD STE 210
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-3658
Practice Address - Country:US
Practice Address - Phone:937-534-4201
Practice Address - Fax:937-291-6941
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053994D207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0631089Medicaid
OH0631089Medicaid
OHH029170Medicare PIN
OH0615144Medicare PIN
080180474Medicare PIN