Provider Demographics
NPI:1336183110
Name:DERAKHSHESH, ALFRED A (DC)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:A
Last Name:DERAKHSHESH
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 1:1470 REXFORD DR
Mailing Address - Street 2:#207
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-3145
Mailing Address - Country:US
Mailing Address - Phone:310-722-0800
Mailing Address - Fax:
Practice Address - Street 1:1016 S ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1505
Practice Address - Country:US
Practice Address - Phone:310-652-9283
Practice Address - Fax:310-652-9292
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24112111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGDC000280Medicaid
CAWDC13867Medicare ID - Type Unspecified
CAGDC000280Medicaid