Provider Demographics
NPI:1215922059
Name:WILLIAMSON, DERRICK (DO)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20755 GREENFIELD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5400
Mailing Address - Country:US
Mailing Address - Phone:947-282-5009
Mailing Address - Fax:248-809-2319
Practice Address - Street 1:20755 GREENFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5400
Practice Address - Country:US
Practice Address - Phone:947-282-5009
Practice Address - Fax:248-809-2319
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDW009333208D00000X
MI5101009333207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1215922059Medicaid
MI437095911Medicaid
MI1215922059Medicaid
MI437095911Medicaid
E40618Medicare UPIN