Provider Demographics
NPI:1164510566
Name:THIEL, DERRICK DANIEL (DO)
Entity type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:DANIEL
Last Name:THIEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 MORRISON RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511
Mailing Address - Country:US
Mailing Address - Phone:813-681-6474
Mailing Address - Fax:813-681-9092
Practice Address - Street 1:214 MORRISON RD
Practice Address - Street 2:SUITE 104
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511
Practice Address - Country:US
Practice Address - Phone:813-681-6474
Practice Address - Fax:813-681-9092
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO1132207R00000X
FLOS9317207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1937700Medicaid
FL001937700Medicaid
145RCOtherBLUE CROSS
FL1937700Medicaid