MEDICARE: DR. JAMES A. DERKSEN MD

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
1	207Q00000X	Family Medicine Physician	35053994D	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932163409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES A. DERKSEN MD

Provider Business Mailing Address
First Line	:	3080 ACKERMAN BLVD STE 210
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45429-3658
Country	:	US
Telephone Number	:	937-534-4201
Fax Number	:	937-291-6941

Provider Business Practice Location Address
First Line	:	3080 ACKERMAN BLVD STE 210
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45429-3658
Country	:	US
Telephone Number	:	937-534-4201
Fax Number	:	937-291-6941

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	02/06/2023

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