Healthcare Provider Details

I. General information

NPI: 1295049070
Provider Name (Legal Business Name): DUSTIN CLIFTON DERRICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 12TH AVE STE 100
FORT WORTH TX
76104-2519
US

IV. Provider business mailing address

800 12TH AVE STE 100
FORT WORTH TX
76104-2519
US

V. Phone/Fax

Practice location:
  • Phone: 817-810-0770
  • Fax: 817-820-0242
Mailing address:
  • Phone: 817-810-0770
  • Fax: 817-820-0242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberQ4085
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number57. 025880
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberQ4085
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: