Basic Information
| Provider Information | |||||||||
| NPI: | 1487683991 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERR | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | RONALD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 DODDS AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374043911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238268220 | ||||||||
| FaxNumber: | 4236983622 | ||||||||
| Practice Location | |||||||||
| Address1: | 807 STEELS POINTE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013315934 | ||||||||
| FaxNumber: | 6018151854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 2085R0202X | 44204 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 18738 | MS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00261751 | 01 | MS | RAILROAD MEDICARE | OTHER | 01536317 | 05 | MS | MEDICAID | 512G700003 | 01 | MS | MS MEDCIARE - GROUP | OTHER |