Provider Demographics
NPI:1659969590
Name:DERRICK TINT MD, CORPORATION
Entity Type:Organization
Organization Name:DERRICK TINT MD, CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:TINT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-246-3072
Mailing Address - Street 1:341 MAGNOLIA AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3332
Mailing Address - Country:US
Mailing Address - Phone:951-735-0470
Mailing Address - Fax:951-735-2706
Practice Address - Street 1:341 MAGNOLIA AVE STE 206
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3332
Practice Address - Country:US
Practice Address - Phone:951-735-0470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA160407OtherMEDICAL LICENSE
1033554423OtherINDIVIDUAL NPI
PAMD463754OtherMEDICAL LICENSE
PAMD463754OtherMEDICAL LICENSE