Basic Information
| Provider Information | |||||||||
| NPI: | 1336236488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARNES | ||||||||
| FirstName: | DERRICK | ||||||||
| MiddleName: | JAY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5196 HILL RD E | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LAKEPORT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954536360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072636885 | ||||||||
| FaxNumber: | 7042636624 | ||||||||
| Practice Location | |||||||||
| Address1: | 5196 HILL RD E | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LAKEPORT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954536360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072636885 | ||||||||
| FaxNumber: | 7042636624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | LL 27176 | SC | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 2008-0337 | NC | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | C133289 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 5910437 | 05 | NC | MEDICAID | 1336236488 | 01 | NC | BLUE MEDICARE | OTHER |