Healthcare Provider Details

I. General information

NPI: 1801040894
Provider Name (Legal Business Name): MARVIN J. DERRICK, M.D. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 OLD RIVER RD SUITE 250
BAKERSFIELD CA
93311-9504
US

IV. Provider business mailing address

PO BOX 22140
BAKERSFIELD CA
93390-2140
US

V. Phone/Fax

Practice location:
  • Phone: 661-664-9990
  • Fax:
Mailing address:
  • Phone: 661-664-9990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberG47855
License Number StateCA

VIII. Authorized Official

Name: MARVIN J DERRICK
Title or Position: OWNER
Credential: MD
Phone: 661-664-9990