Provider Demographics
NPI:1154323715
Name:DERLET, MIKLA NINA (MD)
Entity Type:Individual
Prefix:MRS
First Name:MIKLA
Middle Name:NINA
Last Name:DERLET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:MIKLA
Other - Middle Name:NINA
Other - Last Name:NOPONEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2516 STOCKTON BLVD
Mailing Address - Street 2:DEPARTMENT OF PEDIATRICS
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2208
Mailing Address - Country:US
Mailing Address - Phone:916-734-5387
Mailing Address - Fax:916-456-2236
Practice Address - Street 1:2516 STOCKTON BLVD
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2208
Practice Address - Country:US
Practice Address - Phone:916-734-5387
Practice Address - Fax:916-456-2236
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77577208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A775770Medicaid
H56769Medicare UPIN
CACK938ZMedicare PIN