Basic Information
| Provider Information | |||||||||
| NPI: | 1659352219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADAMS | ||||||||
| FirstName: | DERRICK | ||||||||
| MiddleName: | HENDRICKS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 SISTER MARY COLUMBA DR | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960804356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305270414 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2450 SISTER MARY COLUMBA DR | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960804356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305270414 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 01/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 5101017524 | MI | N | Allopathic & Osteopathic Physicians | Dermatology | 207QA0505X | 20A8900 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | RHM53955F | 05 | CA | MEDICAID | GR0089250 | 05 | CA | MEDICAID |