Provider Demographics
NPI:1730189945
Name:HAMILTON, DERRICK R (MD)
Entity type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:R
Last Name:HAMILTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:214 LAKEVIEW RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SOMERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38068-9737
Mailing Address - Country:US
Mailing Address - Phone:901-516-4082
Mailing Address - Fax:901-516-4092
Practice Address - Street 1:214 LAKEVIEW RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-9737
Practice Address - Country:US
Practice Address - Phone:901-516-4082
Practice Address - Fax:901-516-4092
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38455207PP0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440910Medicaid
TNI13271Medicare UPIN
TN3897402Medicare ID - Type Unspecified