Provider Demographics
NPI:1598184244
Name:PHAN, DEREK Q (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:Q
Last Name:PHAN
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 1:10798 JURUPA RD
Mailing Address - Street 2:PO BOX 136
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91752
Mailing Address - Country:US
Mailing Address - Phone:213-569-1450
Mailing Address - Fax:
Practice Address - Street 1:21634 RETREAT PKWY
Practice Address - Street 2:
Practice Address - City:TEMESCAL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92883-6100
Practice Address - Country:US
Practice Address - Phone:951-493-6650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61123756207R00000X, 207RI0011X
KS0447579207RC0000X, 207RI0011X
CAA138554207RC0000X, 207RI0011X
WI100522207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology