Provider Demographics
NPI:1659471027
Name:DERDAK, STEPHEN (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:DERDAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 FLOYD CURL DR # MC8308
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3931
Mailing Address - Country:US
Mailing Address - Phone:210-450-9000
Mailing Address - Fax:
Practice Address - Street 1:8300 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3931
Practice Address - Country:US
Practice Address - Phone:210-450-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6571207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148199604Medicaid