Provider Demographics
NPI:1699375915
Name:GILLS, DERRICK DARNELL
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:DARNELL
Last Name:GILLS
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 1:18415 NEW HAMPSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2736
Mailing Address - Country:US
Mailing Address - Phone:248-499-4912
Mailing Address - Fax:248-559-2208
Practice Address - Street 1:29935 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1020
Practice Address - Country:US
Practice Address - Phone:248-356-6590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management