Provider Demographics
NPI:1538102660
Name:MYERS, DERRICK MARLIN (MD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:MARLIN
Last Name:MYERS
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 1:90 N MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1740
Mailing Address - Country:US
Mailing Address - Phone:626-291-2525
Mailing Address - Fax:626-898-9244
Practice Address - Street 1:90 N. MADISON AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-6630
Practice Address - Country:US
Practice Address - Phone:626-291-2525
Practice Address - Fax:626-898-9244
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84438207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A844380Medicaid
CAWA84438Medicare PIN
CAH95463Medicare UPIN
CAWA84438FMedicare PIN