Provider Demographics
NPI:1073729588
Name:PHAN, DEREK T (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:T
Last Name:PHAN
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 1:9191 BOLSA AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-5561
Mailing Address - Country:US
Mailing Address - Phone:714-891-7035
Mailing Address - Fax:
Practice Address - Street 1:9191 BOLSA AVE STE 205
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5561
Practice Address - Country:US
Practice Address - Phone:714-891-7035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99908207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine