Provider Demographics
NPI:1417484437
Name:MCCALLA, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MCCALLA
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 1:11175 CAMPUS STREET COLEMAN PAVILION SUITE A1121
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-0001
Mailing Address - Country:US
Mailing Address - Phone:909-558-4174
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON STREET
Practice Address - Street 2:LOMA LINDA UNIVERSITY HEALTH-TRANSITIONAL YEAR
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-6491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA161942208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics