Provider Demographics
NPI:1851075907
Name:DEREK Q PHAN MD MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DEREK Q PHAN MD MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:Q
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-324-3157
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 1:800 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3420
Practice Address - Country:US
Practice Address - Phone:213-569-1450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty