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NPI Code Detail

MEDICARE: GRANT DALE-DERKS DO

MEDICARE: GRANT DALE-DERKS DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1386303550
Entity Type Code : Individual
Provider Name (Legal Business Name) : GRANT DALE-DERKS DO
Provider Business Mailing Address
First Line : 333 HUGUENOT ST APT P112
Second Line :
City : NEW ROCHELLE
State : NY
Zip : 10801-7350
Country : US
Telephone Number : 636-541-8934
Fax Number :
Provider Business Practice Location Address
First Line : 4422 3RD AVE
Second Line :
City : BRONX
State : NY
Zip : 10457-2545
Country : US
Telephone Number : 718-960-9000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/14/2021
Last Update Date : 02/18/2026

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Directions to “ GRANT DALE-DERKS DO” Practice Location

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