Provider Demographics
NPI:1932253606
Name:DERRICK, JOHN BURTON
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BURTON
Last Name:DERRICK
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 1:300 ARLINGTON DR
Mailing Address - Street 2:PO BOX 645
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475
Mailing Address - Country:US
Mailing Address - Phone:912-538-0830
Mailing Address - Fax:
Practice Address - Street 1:300 ARLINGTON DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-0645
Practice Address - Country:US
Practice Address - Phone:912-538-0830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA01655363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA01655OtherLICENSE
GAMD0736504OtherDEA LICENSE
GAMD0736504OtherDEA LICENSE