Provider Demographics
NPI:1548290596
Name:DERDERIAN, HARRY (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:
Last Name:DERDERIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N EAGLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1805
Mailing Address - Country:US
Mailing Address - Phone:859-258-5225
Mailing Address - Fax:859-258-5239
Practice Address - Street 1:100 N EAGLE CREEK DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1805
Practice Address - Country:US
Practice Address - Phone:859-258-5225
Practice Address - Fax:859-258-5239
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22684207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY37903705OtherMEDICAID LAB GRP
GACB5773OtherRR MEDCARE GRP
KY4000501OtherMEDICARE LAB GRP
KY64226848Medicaid
KY37903705OtherMEDICAID LAB GRP
KY64226848Medicaid