Provider Demographics
NPI:1871878165
Name:DEREK P DOTY DC INC
Entity type:Organization
Organization Name:DEREK P DOTY DC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:DOTY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-905-0321
Mailing Address - Street 1:6834 11TH AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423
Mailing Address - Country:US
Mailing Address - Phone:320-905-0321
Mailing Address - Fax:
Practice Address - Street 1:21410 136TH AVE N
Practice Address - Street 2:SUITE 105A
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374
Practice Address - Country:US
Practice Address - Phone:320-905-0321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5449111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350004763Medicare PIN