=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720122203
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEREK GAVIN VINES M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2007
-----------------------------------------------------
Last Update Date | 03/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 950 W. GRANT ST. STUDENT WELLNESS CENTER MEDICAL SERVICES, SUITE 2200
-----------------------------------------------------
City | BOZEMAN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-994-2311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 FLYNN AVE SUITE 3J
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05401-5429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 26173
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------