Healthcare Provider Details

I. General information

NPI: 1588973945
Provider Name (Legal Business Name): DERRICK S HINES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 10/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15648 N 35TH AVE
PHOENIX AZ
85053-3861
US

IV. Provider business mailing address

15648 N 35TH AVE
PHOENIX AZ
85053-3861
US

V. Phone/Fax

Practice location:
  • Phone: 623-930-8705
  • Fax: 602-732-4980
Mailing address:
  • Phone: 623-930-8705
  • Fax: 602-732-4980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number31380
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: