Provider Demographics
NPI:1043275712
Name:DERR, KEITH EDWARD (IDC)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:EDWARD
Last Name:DERR
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4837 PEACHCREEK LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-5326
Mailing Address - Country:US
Mailing Address - Phone:757-518-9726
Mailing Address - Fax:
Practice Address - Street 1:USS WHIDBEY ISLAND
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09591-1727
Practice Address - Country:US
Practice Address - Phone:757-462-7526
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman