Provider Demographics
NPI:1992837520
Name:CARMONA, DEREK PETER (DC)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:PETER
Last Name:CARMONA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 S SUNSET AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3410
Mailing Address - Country:US
Mailing Address - Phone:626-851-4003
Mailing Address - Fax:626-851-0223
Practice Address - Street 1:933 S SUNSET AVE STE 103
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3410
Practice Address - Country:US
Practice Address - Phone:626-851-4003
Practice Address - Fax:626-851-0223
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26691111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0266910OtherBLUE SHIELD
CADC1019793OtherASHP
CADC1019793OtherASHP