Provider Demographics
NPI:1538241799
Name:EARL, DEREK TED (DO)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:TED
Last Name:EARL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 NE 12TH ST
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-2598
Mailing Address - Country:US
Mailing Address - Phone:541-567-3643
Mailing Address - Fax:541-567-6019
Practice Address - Street 1:600 NW 11TH ST
Practice Address - Street 2:SUITE E-15
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-8602
Practice Address - Country:US
Practice Address - Phone:541-567-6434
Practice Address - Fax:541-567-6019
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001751207Q00000X
ORDO23298207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR298007Medicaid
OR298007Medicaid
ORR116521Medicare PIN