Provider Demographics
NPI:1801221890
Name:TOM, DERICK
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:
Last Name:TOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 N. BEVERLY PLAZA APT#142
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815
Mailing Address - Country:US
Mailing Address - Phone:909-993-7663
Mailing Address - Fax:
Practice Address - Street 1:2021 N. BEVERLY PLAZA APT#142
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815
Practice Address - Country:US
Practice Address - Phone:909-993-7663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program