MEDICARE: MR. DEREK TYLER WEBSTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1265910665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DEREK TYLER WEBSTER

Provider Business Mailing Address
First Line	:	50 ELK LN
Second Line	:
City	:	ELKTON
State	:	MD
Zip	:	21921-7912
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 N FAIRFAX AVE
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90046-7207
Country	:	US
Telephone Number	:	323-653-1521
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2018
Last Update Date	:	07/30/2018

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