Provider Demographics
NPI:1497416598
Name:ANDERSON, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3624 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63107-3703
Mailing Address - Country:US
Mailing Address - Phone:314-541-8131
Mailing Address - Fax:
Practice Address - Street 1:3624 N 14TH ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63107-3703
Practice Address - Country:US
Practice Address - Phone:314-541-8131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-01
Last Update Date:2022-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2010014757246ZC0007X
MO2010014757332BC3200X, 343900000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)