Provider Demographics
NPI:1609876606
Name:ANDERSON, DERRICK (MD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-703-7003
Mailing Address - Fax:704-865-4614
Practice Address - Street 1:1831 N FAYETTEVILLE ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-3273
Practice Address - Country:US
Practice Address - Phone:336-672-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-02612207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026494200Medicaid
NE10026451700Medicaid
04012OtherBCBS
NE47082189713Medicaid
NE10025024300Medicaid
NE1002466400Medicaid
NE10024946900Medicaid
NE10025024400Medicaid
NE10026476700Medicaid
NE10026494200Medicaid
NE10026476700Medicaid
NE10026451700Medicaid