Provider Demographics
NPI:1194268458
Name:MATTHIES, DEREK WILLIAM
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:WILLIAM
Last Name:MATTHIES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11622 HUNTER IVY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-5866
Mailing Address - Country:US
Mailing Address - Phone:714-904-4463
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DRIVE, SUITE 1 ATTN: CREDENTIALS (SGHC)
Practice Address - Street 2:JBSA-LACKLAND
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:714-904-4463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-18
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program