Provider Demographics
NPI:1245465178
Name:DERRICK, BRANDI L (MD)
Entity type:Individual
Prefix:DR
First Name:BRANDI
Middle Name:L
Last Name:DERRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7033 SAINT ANDREWS RD STE 305
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1181
Practice Address - Country:US
Practice Address - Phone:803-779-3378
Practice Address - Fax:803-779-3103
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA68741207R00000X
SC35179207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1883689Medicaid