Healthcare Provider Details

I. General information

NPI: 1194015313
Provider Name (Legal Business Name): DEREK A BANYARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S MANCHESTER AVE SUITE 650
ORANGE CA
92868-3217
US

IV. Provider business mailing address

200 S MANCHESTER AVE SUITE 650
ORANGE CA
92868-3217
US

V. Phone/Fax

Practice location:
  • Phone: 714-939-4028
  • Fax:
Mailing address:
  • Phone: 714-939-4028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA124088
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: