Healthcare Provider Details

I. General information

NPI: 1902485840
Provider Name (Legal Business Name): DEREK WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 NICHOLASVILLE RD
LEXINGTON KY
40503-1431
US

IV. Provider business mailing address

425 LEWIS HARGETT CIR
LEXINGTON KY
40503-3590
US

V. Phone/Fax

Practice location:
  • Phone: 859-268-1030
  • Fax: 859-269-4120
Mailing address:
  • Phone: 859-268-1030
  • Fax: 859-269-4120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberTP229
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: