Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | 036126121 | IL |
NPI | 1295720845 |
---|---|
Provider Name | Dr. Richard Derby |
First Address | O Fallon, IL 62269-2579 |
Second Address | O Fallon, IL 62269-2579 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2005 |
Last Update Date | 29/12/2021 |