Provider Demographics
NPI:1235153040
Name:TARN, DERJUNG
Entity Type:Individual
Prefix:
First Name:DERJUNG
Middle Name:
Last Name:TARN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-794-8242
Mailing Address - Fax:310-794-6097
Practice Address - Street 1:1920 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3414
Practice Address - Country:US
Practice Address - Phone:310-319-4700
Practice Address - Fax:310-794-6097
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72710207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A727100Medicaid
CAWA72710CMedicare PIN
CAH77975Medicare UPIN