Provider Demographics
NPI:1154051308
Name:RYAN DERBY, MD CORP.
Entity Type:Organization
Organization Name:RYAN DERBY, MD CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DERBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:650-814-6188
Mailing Address - Street 1:1330 TARA HILLS DR STE E105
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2531
Mailing Address - Country:US
Mailing Address - Phone:650-814-6188
Mailing Address - Fax:
Practice Address - Street 1:1330 TARA HILLS DR STE E105
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2531
Practice Address - Country:US
Practice Address - Phone:650-814-6188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty