=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811591290
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK TERRENCE DERREVERE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2020
-----------------------------------------------------
Last Update Date | 12/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | LONE TREE MEDICAL CENTER 9548 PARK MEADOWS DRIVE
-----------------------------------------------------
City | LONE TREE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-281-8114
-----------------------------------------------------
Fax | 720-553-0901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | LONE TREE MEDICAL CENTER 9548 PARK MEADOWS DRIVE
-----------------------------------------------------
City | LONE TREE
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-281-8114
-----------------------------------------------------
Fax | 720-553-0901
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XH1200X
-----------------------------------------------------
Taxonomy Name | Hand Occupational Therapist
-----------------------------------------------------
License Number | OT.0001549
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT.0001549
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225XH1200X
-----------------------------------------------------
Taxonomy Name | Hand Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------