Provider Demographics
NPI:1548242589
Name:TAGGARD, DEREK ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:ALLAN
Last Name:TAGGARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 E RIVER PARK PL W STE 104
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-1565
Practice Address - Country:US
Practice Address - Phone:559-320-0530
Practice Address - Fax:559-320-0532
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80229207T00000X
TXQ4855207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A802290Medicaid
CA00A802290Medicaid
CA00A802290Medicare ID - Type Unspecified