Provider Demographics
NPI:1366637159
Name:SMITH, DERRICK
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 1/2 N MAGNOLIA AVE
Mailing Address - Street 2:APT 228
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-3148
Mailing Address - Country:US
Mailing Address - Phone:562-537-9068
Mailing Address - Fax:
Practice Address - Street 1:100 E WARDLOW RD
Practice Address - Street 2:LONG BEACH
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-4417
Practice Address - Country:US
Practice Address - Phone:562-427-6818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator