Provider Demographics
NPI:1508037631
Name:SONTAG, DERRY (DC)
Entity Type:Individual
Prefix:
First Name:DERRY
Middle Name:
Last Name:SONTAG
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 1:15550 ROCKFIELD BLVD
Mailing Address - Street 2:B220
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2720
Mailing Address - Country:US
Mailing Address - Phone:949-598-9999
Mailing Address - Fax:949-598-9999
Practice Address - Street 1:2305 CARLOS ST
Practice Address - Street 2:B
Practice Address - City:MOSS BEACH
Practice Address - State:CA
Practice Address - Zip Code:94038-9666
Practice Address - Country:US
Practice Address - Phone:650-728-7106
Practice Address - Fax:650-728-5459
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29103111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC29103OtherLICENSE