Provider Demographics
NPI:1497725758
Name:DARNSTEADT, DERRICK R (MD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:R
Last Name:DARNSTEADT
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 1:1825 WESTHOLME AVE APT 5
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4954
Mailing Address - Country:US
Mailing Address - Phone:310-801-8546
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-268-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92752207P00000X, 208D00000X
ALMD.30306207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1497725758OtherTRICARE SOUTH
ALZ10777OtherVIVA HEALTH
AL122003Medicaid
AL128507Medicaid
AL511-09380OtherBCBS
AL102I930548Medicare PIN