Healthcare Provider Details

I. General information

NPI: 1760286421
Provider Name (Legal Business Name): DERRICA MCCALLA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL RIDGE DR
GREENVILLE SC
29605-4267
US

IV. Provider business mailing address

20 MEDICAL RIDGE DR
GREENVILLE SC
29605-4267
US

V. Phone/Fax

Practice location:
  • Phone: 864-522-5220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL94538
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: