Provider Demographics
NPI:1508811753
Name:RICHARD DERBY MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:RICHARD DERBY MD A PROFESSIONAL CORPORATION
Other - Org Name:COMPREHENSIVE SPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:FIONNUALA
Authorized Official - Middle Name:
Authorized Official - Last Name:MC ELLIGOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-755-5096
Mailing Address - Street 1:901 CAMPUS DRIVE
Mailing Address - Street 2:#312
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015
Mailing Address - Country:US
Mailing Address - Phone:650-755-0733
Mailing Address - Fax:650-755-3018
Practice Address - Street 1:901 CAMPUS DRIVE
Practice Address - Street 2:#312
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015
Practice Address - Country:US
Practice Address - Phone:650-755-0733
Practice Address - Fax:650-755-3018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG24348OtherCALIF BOARD
00G243480Medicare ID - Type Unspecified
A42235Medicare UPIN