Healthcare Provider Details

I. General information

NPI: 1003801267
Provider Name (Legal Business Name): WILFRED DERKSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1570 E HERNDON AVE
FRESNO CA
93720-3303
US

IV. Provider business mailing address

PO BOX 28900
FRESNO CA
93729-8900
US

V. Phone/Fax

Practice location:
  • Phone: 559-437-7300
  • Fax: 559-437-7153
Mailing address:
  • Phone: 559-228-4205
  • Fax: 559-224-3920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC33691
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: