Provider Demographics
NPI:1477736106
Name:JEROLD A. DERKAZ, MD PA
Entity type:Organization
Organization Name:JEROLD A. DERKAZ, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCABASCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-892-6600
Mailing Address - Street 1:1290 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-2505
Mailing Address - Country:US
Mailing Address - Phone:850-892-6600
Mailing Address - Fax:850-520-4660
Practice Address - Street 1:1290 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-2505
Practice Address - Country:US
Practice Address - Phone:850-892-6600
Practice Address - Fax:850-520-4660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0046412207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL76015OtherBCBS
FLK3534OtherMEDICARE ID
FL262982800Medicaid
FL76015OtherBCBS