Basic Information
| Provider Information | |||||||||
| NPI: | 1992788095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DETEMPLE | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1741 E MORTEN AVE STE C1 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850204645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028700194 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1741 E MORTEN AVE STE C1 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850204645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028700194 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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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 | 207P00000X | 3763 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 695942 | 05 | AZ | MEDICAID | AW1436 | 01 | AZ | HEALTHNET - GROUP # | OTHER | AZ0728670 | 01 | AZ | BLUE CROSS BLUE SHIELD | OTHER | 3981220 | 01 | AZ | EVERCARE - GROUP # | OTHER |