Basic Information
| Provider Information | |||||||||
| NPI: | 1023035524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DERICKSON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | LYLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 N GRAND AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | NOGALES | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856211061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207612133 | ||||||||
| FaxNumber: | 5202812335 | ||||||||
| Practice Location | |||||||||
| Address1: | 1852 N MASTICK WAY | ||||||||
| Address2: | |||||||||
| City: | NOGALES | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202811550 | ||||||||
| FaxNumber: | 5202814487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 11/28/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 37067 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 266946 | 05 | AZ | MEDICAID |