NPIMap

Individual provider Active NPI

Todd Alan Derksen, DPM

  • Foot & Ankle Surgery Podiatrist
  • Appleton, WI
National Provider Identifier
1053578682
Registry record updated Aug 19, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Foot & Ankle Surgery PodiatristTaxonomy code 213ES0103X
License
953-25 Issued in WI
Practice address
1301 E Northland Ave
Ste B
Appleton, WI 54911
Phone
(920) 731-1999
Fax
(920) 731-3729
NPI assigned
May 21, 2008
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Aug 19, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Foot & Ankle Surgery Podiatrist 213ES0103X 953-25 WI Primary

Addresses

Primary practice location

1301 E Northland Ave
Ste B
Appleton, WI 54911

Mailing address

1301 E Northland Ave
Ste B
Appleton, WI 54911
Phone (920) 702-5484

Other identifiers 1

IdentifierTypeStateIssuer
43244900MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20080904000627 WI Practitioner - Podiatry 5496821068 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Podiatry
Education
Other, 2005
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Northeast Wisconsin Foot and Ankle Assoc SCGroup PAC ID 8527000850, 4 clinicians

Practice addresses (Care Compare)

1301 E Northland Ave
Suite B
Appleton, WI 54911-8582
Phone (920) 702-5484

Hospital & facility affiliations

  • Thedacare Regional Medical Center - Appleton Inc Hospital, Appleton, WI, CCN 520160

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of tissue1-10
Removal of nail tissue1-10
Removal or shaving of skin growth1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
953-25WIMDFoot & Ankle Surgery Podiatrist

Practice roles

OrganizationSpecialtyStatusNew patients
Northeast Wisconsin Foot and Ankle Assoc., S.C. Foot & Ankle Surgery CurrentSince Jun 1, 2022 Accepting new patients
Northeast Wisconsin Foot and Ankle Assoc., S.C. CurrentSince Jun 1, 2022 Accepting new patients

Locations

1301 E Northland Ave
Ste B
Appleton, WI 54911
Phone (920) 702-5484

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1211328000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1660867200000",
    "number": "1053578682",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1301 E NORTHLAND AVE",
            "address_2": "STE B",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "54911",
            "telephone_number": "920-702-5484",
            "fax_number": "920-731-1999"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1301 E NORTHLAND AVE",
            "address_2": "STE B",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "54911",
            "telephone_number": "920-731-1999",
            "fax_number": "920-731-3729"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DERKSEN",
        "first_name": "TODD",
        "middle_name": "ALAN",
        "name_prefix": "Dr.",
        "credential": "DPM",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-05-21",
        "last_updated": "2022-08-19",
        "certification_date": "2022-08-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "213ES0103X",
            "taxonomy_group": "",
            "desc": "Podiatrist, Foot & Ankle Surgery",
            "state": "WI",
            "license": "953-25",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "43244900",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Appleton, WI

Sources for this page

Verify at the official NPI Registry.