Provider Demographics
NPI:1699779090
Name:DERDERIAN, RAYMOND (MD)
Entity type:Individual
Prefix:PROF
First Name:RAYMOND
Middle Name:
Last Name:DERDERIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2965 HARRISON ST
Mailing Address - Street 2:STE 317
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1150
Mailing Address - Country:US
Mailing Address - Phone:409-554-0911
Mailing Address - Fax:409-554-0912
Practice Address - Street 1:2965 HARRISON ST
Practice Address - Street 2:STE 317
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1150
Practice Address - Country:US
Practice Address - Phone:409-554-0911
Practice Address - Fax:409-554-0912
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH0043207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113566701Medicaid
TX113566701Medicaid
TX262268Medicare Oscar/Certification