Healthcare Provider Details

I. General information

NPI: 1407832579
Provider Name (Legal Business Name): DERRICK OLIVER CLUNIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13535 NEMOURS PKWY NEMOURS CHILDRENS HOSPITAL
ORLANDO FL
32827-7402
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT DEPARTMENT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 407-567-4000
  • Fax:
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME78560
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME78560
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2021012259
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: