Healthcare Provider Details

I. General information

NPI: 1568774362
Provider Name (Legal Business Name): DEREK GUY ZICKGRAF DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3175 POCAHONTAS RD
BAKER CITY OR
97814
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 541-523-4415
  • Fax: 541-523-2399
Mailing address:
  • Phone: 541-523-4415
  • Fax: 541-523-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO181773
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: