Basic Information
| Provider Information | |||||||||
| NPI: | 1477532299 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IPSEN | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | FOSTER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 JARRETT WHITE RD | ||||||||
| Address2: | TRIPLER ARMY MEDICAL CENTER ATTN: MCHK-QS | ||||||||
| City: | TRIPLER AMC | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968595001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084332460 | ||||||||
| FaxNumber: | 8084331558 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 JARRETT WHITE RD | ||||||||
| Address2: | TRIPLER ARMY MEDICAL CENTER | ||||||||
| City: | TRIPLER AMC | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968595001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084332460 | ||||||||
| FaxNumber: | 8084331558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 2001004848 | MO | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | O-1368 | ID | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1477532299 | 05 | MO | MEDICAID |