Provider Demographics
NPI:1841844115
Name:VAN DOREN, JOHN DERRICK (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DERRICK
Last Name:VAN DOREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42222 RANCHO LAS PALMAS DR UNIT 986
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4268
Mailing Address - Country:US
Mailing Address - Phone:951-375-7966
Mailing Address - Fax:
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:951-375-7966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60750207LA0401X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine