Healthcare Provider Details

I. General information

NPI: 1780655613
Provider Name (Legal Business Name): PAUL J DERDEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 PRINCETON RD STE 10
JOHNSON CITY TN
37601-2062
US

IV. Provider business mailing address

1021 W OAKLAND AVE STE 310
JOHNSON CITY TN
37604-2192
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-7340
  • Fax:
Mailing address:
  • Phone: 423-302-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101036190
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: