Provider Demographics
NPI:1871618504
Name:DERDEYN, AMALIE S (MD)
Entity type:Individual
Prefix:DR
First Name:AMALIE
Middle Name:S
Last Name:DERDEYN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 BERKMAR DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901
Mailing Address - Country:US
Mailing Address - Phone:434-923-4651
Mailing Address - Fax:434-964-3636
Practice Address - Street 1:3350 BERKMAR DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901
Practice Address - Country:US
Practice Address - Phone:434-923-4651
Practice Address - Fax:434-964-3636
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241359207N00000X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA11718431OtherCAQH PROVIDER #