Healthcare Provider Details

I. General information

NPI: 1508037631
Provider Name (Legal Business Name): DERRY SONTAG D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 CARLOS ST B
MOSS BEACH CA
94038-9666
US

IV. Provider business mailing address

15550 ROCKFIELD BLVD B220
IRVINE CA
92618-2720
US

V. Phone/Fax

Practice location:
  • Phone: 650-728-7106
  • Fax: 650-728-5459
Mailing address:
  • Phone: 949-598-9999
  • Fax: 949-598-9999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC29103
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: