Healthcare Provider Details

I. General information

NPI: 1750673539
Provider Name (Legal Business Name): DERICK R FENTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2011
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5417 S COMMERCE DR STE 100
MURRAY UT
84107-5803
US

IV. Provider business mailing address

5655 E BEVERLY LN
SCOTTSDALE AZ
85254-9206
US

V. Phone/Fax

Practice location:
  • Phone: 248-508-1266
  • Fax:
Mailing address:
  • Phone: 248-508-1266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number14257374-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDR.0055326
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: