Provider Demographics
NPI:1215773197
Name:DERRICK CHI, FONTEM
Entity type:Individual
Prefix:
First Name:FONTEM
Middle Name:
Last Name:DERRICK CHI
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 1:4827 INDIAN LN
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-1661
Mailing Address - Country:US
Mailing Address - Phone:240-549-0209
Mailing Address - Fax:
Practice Address - Street 1:4827 INDIAN LN
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-1661
Practice Address - Country:US
Practice Address - Phone:240-549-0209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker