Provider Demographics
NPI:1861832230
Name:MCALLISTER, DEREK GLEN (DO)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:GLEN
Last Name:MCALLISTER
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 1:300 PASTEUR DR
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-723-4000
Mailing Address - Fax:
Practice Address - Street 1:2428 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2045
Practice Address - Country:US
Practice Address - Phone:310-315-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010203332085R0202X
CA20A164742085R0202X, 2085D0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology