1336658301 NPI number — MR. DEREK DOSS

Table of content: MR. DEREK DOSS (NPI 1336658301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336658301 NPI number — MR. DEREK DOSS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOSS
Provider First Name:
DEREK
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336658301
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
10/26/2023
NPI Reactivation Date:
11/08/2023

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5760 PATRIOT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTINTOWN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44515-1170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-259-8813
Provider Business Mailing Address Fax Number:
330-953-0243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
960 BOARDMAN CANFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOARDMAN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44512-4220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-259-8813
Provider Business Practice Location Address Fax Number:
330-270-2690
Provider Enumeration Date:
09/21/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)