Healthcare Provider Details

I. General information

NPI: 1760463889
Provider Name (Legal Business Name): DEREK J MCCAMMON D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24076 SE STARK ST STE 110
GRESHAM OR
97030-3374
US

IV. Provider business mailing address

24076 SE STARK ST STE 110
GRESHAM OR
97030-3374
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-5388
  • Fax: 503-666-9393
Mailing address:
  • Phone: 503-661-5388
  • Fax: 503-666-9393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberDP00307
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier235116
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: