Provider Demographics
NPI:1912172438
Name:PLONKA, DEREK ANTHONY (DPT, MTOM)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:ANTHONY
Last Name:PLONKA
Suffix:
Gender:M
Credentials:DPT, MTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 WILSHIRE BLVD.
Mailing Address - Street 2:SUITE 605
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-453-8668
Mailing Address - Fax:310-453-8662
Practice Address - Street 1:1821 WILSHIRE BLVD.
Practice Address - Street 2:SUITE 605
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-453-8668
Practice Address - Fax:310-453-8662
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI02322225100000X
CAPT25134225100000X
CA16420171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT25134AMedicare PIN