Provider Demographics
NPI:1700202843
Name:SCOTT, DERRICK (CDRS)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:SCOTT
Suffix:
Gender:M
Credentials:CDRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2039 21ST AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94116-1208
Mailing Address - Country:US
Mailing Address - Phone:415-336-8916
Mailing Address - Fax:415-267-6118
Practice Address - Street 1:1904 FRANKLIN ST
Practice Address - Street 2:SUITE 330
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2912
Practice Address - Country:US
Practice Address - Phone:510-444-8900
Practice Address - Fax:415-267-6118
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN6309804172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver