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General NPI Number Information
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NPI Number | 1477736106
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Entity Type | Organization
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Legal Business Name | JEROLD A. DERKAZ, MD PA
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Dates
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Enumeration Date | 12/17/2007
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Last Update Date | 05/19/2011
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Provider Practice Location Address
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Address Line | 1290 CIRCLE DR
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City | DEFUNIAK SPRINGS
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State | FL
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Zip | 32435-2505
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Country | US
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Telephone | 850-892-6600
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Fax | 850-520-4660
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Provider Business Mailing Address
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Address Line | 1290 CIRCLE DR
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City | DEFUNIAK SPRINGS
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State | FL
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Zip | 32435-2505
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Country | US
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Telephone | 850-892-6600
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Fax | 850-520-4660
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Authorized Official
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Title or Position | RECEPTIONIST
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Name | AMANDA ARCABASCIO
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Credential |
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Telephone | 850-892-6600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME0046412
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License Number State | FL
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