Healthcare Provider Details

I. General information

NPI: 1750673539
Provider Name (Legal Business Name): DERICK R FENTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 S 3RD
MONTROSE CO
81401
US

IV. Provider business mailing address

715 S 3RD
MONTROSE CO
81401
US

V. Phone/Fax

Practice location:
  • Phone: 970-249-6737
  • Fax: 970-252-0112
Mailing address:
  • Phone: 970-249-6737
  • Fax: 970-252-0112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDR.0055326
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: