1508037631 NPI number — DERRY SONTAG D.C.

Table of content: DERRY SONTAG D.C. (NPI 1508037631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508037631 NPI number — DERRY SONTAG D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SONTAG
Provider First Name:
DERRY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508037631
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15550 ROCKFIELD BLVD
Provider Second Line Business Mailing Address:
B220
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92618-2720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-598-9999
Provider Business Mailing Address Fax Number:
949-598-9999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2305 CARLOS ST
Provider Second Line Business Practice Location Address:
B
Provider Business Practice Location Address City Name:
MOSS BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94038-9666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-728-7106
Provider Business Practice Location Address Fax Number:
650-728-5459
Provider Enumeration Date:
03/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC29103 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DC29103 . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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