MEDICARE: PAUL J DERDEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0101036190	VA

General Provider Information

NPI Number	:	1780655613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL J DERDEN MD

Provider Business Mailing Address
First Line	:	1021 W OAKLAND AVE STE 310
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-2192
Country	:	US
Telephone Number	:	423-302-6565
Fax Number	:

Provider Business Practice Location Address
First Line	:	403 PRINCETON RD STE 10
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-2062
Country	:	US
Telephone Number	:	423-431-7340
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	08/20/2024

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