Healthcare Provider Details

I. General information

NPI: 1932177607
Provider Name (Legal Business Name): RICHARD DERNER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 FINANCIAL LOOP
LAKE RIDGE VA
22192-2460
US

IV. Provider business mailing address

1721 FINANCIAL LOOP
LAKE RIDGE VA
22192-2460
US

V. Phone/Fax

Practice location:
  • Phone: 703-491-9500
  • Fax:
Mailing address:
  • Phone: 703-491-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103000824
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: