Basic Information
| Provider Information | |||||||||
| NPI: | 1760787287 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERRICK UMPHLETT MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8970 E RAINTREE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852607300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806099300 | ||||||||
| FaxNumber: | 4806099350 | ||||||||
| Practice Location | |||||||||
| Address1: | 5102 W CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850311703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806099300 | ||||||||
| FaxNumber: | 4806099350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2011 | ||||||||
| LastUpdateDate: | 06/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | UMPHLETT | ||||||||
| AuthorizedOfficialFirstName: | DERRICK | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4806099300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 684468 | 05 | AZ | MEDICAID |