Healthcare Provider Details

I. General information

NPI: 1649291667
Provider Name (Legal Business Name): DERRICK WAYNE SPELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 ESSEN LN SUITE 500
BATON ROUGE LA
70809-3738
US

IV. Provider business mailing address

PO BOX 84460
BATON ROUGE LA
70884-4460
US

V. Phone/Fax

Practice location:
  • Phone: 225-767-1311
  • Fax: 225-767-1335
Mailing address:
  • Phone: 225-526-0018
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD.023882
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: