Provider Demographics
NPI:1184770406
Name:SUEKI, DERRICK GEORGE (DPT)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:GEORGE
Last Name:SUEKI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2293 SIMON ST
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-5031
Mailing Address - Country:US
Mailing Address - Phone:714-870-7720
Mailing Address - Fax:714-750-4616
Practice Address - Street 1:13341 GARDEN GROVE BLVD STE B
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-2255
Practice Address - Country:US
Practice Address - Phone:714-750-4097
Practice Address - Fax:714-750-4616
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT237152251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT23715CMedicare UPIN