Provider Demographics
NPI:1477914307
Name:DERYNCK, MIKA KAKEFUDA (MD)
Entity Type:Individual
Prefix:
First Name:MIKA
Middle Name:KAKEFUDA
Last Name:DERYNCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 HILLTOP RD
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-1146
Mailing Address - Country:US
Mailing Address - Phone:415-999-3933
Mailing Address - Fax:
Practice Address - Street 1:27 HILLTOP RD
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-1146
Practice Address - Country:US
Practice Address - Phone:415-999-3933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-20
Last Update Date:2016-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGO79889174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGO79889OtherCALIFORNIA MEDICAL LICENSE