Provider Demographics
NPI:1679775951
Name:MARVIN J. DERRICK
Entity type:Organization
Organization Name:MARVIN J. DERRICK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-377-8346
Mailing Address - Street 1:3838 SAN DIMAS ST
Mailing Address - Street 2:STE A100
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-2284
Mailing Address - Country:US
Mailing Address - Phone:661-377-8346
Mailing Address - Fax:661-327-0921
Practice Address - Street 1:3838 SAN DIMAS ST
Practice Address - Street 2:STE A100
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2284
Practice Address - Country:US
Practice Address - Phone:661-377-8346
Practice Address - Fax:661-327-0921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G478550Medicaid
CA00G478550Medicare PIN