Provider Demographics
NPI:1083923585
Name:DERRICK M. DESILVA, JR. MD
Entity Type:Organization
Organization Name:DERRICK M. DESILVA, JR. MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:DESILVA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:732-738-8801
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:629 AMBOY AVE
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-3579
Practice Address - Country:US
Practice Address - Phone:732-738-8801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERRICK M. DESILVA, JR. MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-30
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site