Provider Demographics
NPI:1952938847
Name:PRIDE, DEREK ANTHONY
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:ANTHONY
Last Name:PRIDE
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:PO BOX 3439
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-0439
Mailing Address - Country:US
Mailing Address - Phone:843-839-4447
Mailing Address - Fax:
Practice Address - Street 1:945 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4612
Practice Address - Country:US
Practice Address - Phone:843-497-5929
Practice Address - Fax:866-778-9608
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83289207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine