Provider Demographics
NPI:1336320688
Name:DEPERIO, MIGUEL GAERLAN (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:GAERLAN
Last Name:DEPERIO
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 1:14476 ALDER DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92880-3517
Mailing Address - Country:US
Mailing Address - Phone:951-356-5730
Mailing Address - Fax:
Practice Address - Street 1:301 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1995
Practice Address - Country:US
Practice Address - Phone:949-642-2734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43710207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA43710OtherCA MEDICAL LICENSE
CAA43710OtherCA MEDICAL LICENSE