Healthcare Provider Details

I. General information

NPI: 1467383638
Provider Name (Legal Business Name): DERECK EMANUEL COLON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DERECK COLON BAYONA

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S UNIVERSITY DR
DAVIE FL
33328-2018
US

IV. Provider business mailing address

3890 SW 64TH AVE APT 443
DAVIE FL
33314-2590
US

V. Phone/Fax

Practice location:
  • Phone: 787-539-1489
  • Fax:
Mailing address:
  • Phone: 787-539-1489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPSI46057
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: