Provider Demographics
NPI:1386303550
Name:DALE-DERKS, GRANT (DO)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:DALE-DERKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:GRANT
Other - Middle Name:
Other - Last Name:DALE DERKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:333 HUGUENOT ST APT P112
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-7350
Mailing Address - Country:US
Mailing Address - Phone:636-541-8934
Mailing Address - Fax:
Practice Address - Street 1:4422 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2545
Practice Address - Country:US
Practice Address - Phone:718-960-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program