Healthcare Provider Details

I. General information

NPI: 1790917656
Provider Name (Legal Business Name): DEREK WYMAN THOMSON D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 03/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 W CENTRAL AVE
CAMDEN OH
45311-1007
US

IV. Provider business mailing address

79 W CENTRAL AVE
CAMDEN OH
45311-1007
US

V. Phone/Fax

Practice location:
  • Phone: 937-452-1201
  • Fax: 937-452-0004
Mailing address:
  • Phone: 937-452-1201
  • Fax: 937-452-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-010834
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: