Provider Demographics
NPI:1235225467
Name:DOBALIAN, DEREK MARC (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:MARC
Last Name:DOBALIAN
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 1:3816 WOODRUFF AVE
Mailing Address - Street 2:STE # 307
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808
Mailing Address - Country:US
Mailing Address - Phone:562-420-7670
Mailing Address - Fax:562-429-4064
Practice Address - Street 1:3816 WOODRUFF AVE
Practice Address - Street 2:STE # 307
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808
Practice Address - Country:US
Practice Address - Phone:562-420-7670
Practice Address - Fax:562-429-4064
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48996207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G489960Medicaid
A92866Medicare UPIN
G48996Medicare ID - Type Unspecified