Healthcare Provider Details

I. General information

NPI: 1467573618
Provider Name (Legal Business Name): DERWENT O DANIEL NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 MAGNOLIA STREET
WEST BLOCTON AL
35184
US

IV. Provider business mailing address

2731 MLK JR BLVD
TUSCALOOSA AL
35401-5235
US

V. Phone/Fax

Practice location:
  • Phone: 205-938-9508
  • Fax: 205-938-9550
Mailing address:
  • Phone: 205-349-3250
  • Fax: 205-345-3993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: