Healthcare Provider Details

I. General information

NPI: 1275989402
Provider Name (Legal Business Name): DERRICK HEYDINGER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2016
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 CENTRAL AVE STE 700
CLARK NJ
07066-1121
US

IV. Provider business mailing address

PO BOX 416457
BOSTON MA
02241-6457
US

V. Phone/Fax

Practice location:
  • Phone: 973-943-5042
  • Fax: 973-943-5032
Mailing address:
  • Phone: 844-362-1735
  • Fax: 973-290-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number58.007498
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: