Healthcare Provider Details

I. General information

NPI: 1215922059
Provider Name (Legal Business Name): DERRICK WILLIAMSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20755 GREENFIELD RD STE 100
SOUTHFIELD MI
48075-5400
US

IV. Provider business mailing address

20755 GREENFIELD RD STE 100
SOUTHFIELD MI
48075-5400
US

V. Phone/Fax

Practice location:
  • Phone: 947-282-5009
  • Fax: 248-809-2319
Mailing address:
  • Phone: 947-282-5009
  • Fax: 248-809-2319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDW009333
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101009333
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: