Healthcare Provider Details

I. General information

NPI: 1669162616
Provider Name (Legal Business Name): DEREK S VERSALLE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 TRADE CENTRE WAY
PORTAGE MI
49002-0487
US

IV. Provider business mailing address

950 TRADE CENTRE WAY STE 230
PORTAGE MI
49002-0492
US

V. Phone/Fax

Practice location:
  • Phone: 269-370-1824
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5151016178
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: