Healthcare Provider Details

I. General information

NPI: 1053578682
Provider Name (Legal Business Name): TODD ALAN DERKSEN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 E NORTHLAND AVE STE B
APPLETON WI
54911
US

IV. Provider business mailing address

1301 E NORTHLAND AVE STE B
APPLETON WI
54911
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-1999
  • Fax: 920-731-3729
Mailing address:
  • Phone: 920-702-5484
  • Fax: 920-731-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number953-25
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: