Provider Demographics
NPI:1023572203
Name:MATEO, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MATEO
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 1:11982 DAPPLE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-5245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 34TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2416
Practice Address - Country:US
Practice Address - Phone:619-232-2946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant