Healthcare Provider Details

I. General information

NPI: 1053165357
Provider Name (Legal Business Name): DEREK PARADIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 JONES BRIDGE RD
BETHESDA MD
20814-4712
US

IV. Provider business mailing address

4301 JONES BRIDGE RD
BETHESDA MD
20814-4712
US

V. Phone/Fax

Practice location:
  • Phone: 800-515-5257
  • Fax:
Mailing address:
  • Phone: 800-515-5257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101287208
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: