Healthcare Provider Details

I. General information

NPI: 1598293235
Provider Name (Legal Business Name): EDWARD MATTHEW DEGERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19950 RINALDI ST
PORTER RANCH CA
91326-4141
US

IV. Provider business mailing address

19950 RINALDI ST
PORTER RANCH CA
91326-4141
US

V. Phone/Fax

Practice location:
  • Phone: 818-403-2400
  • Fax:
Mailing address:
  • Phone: 818-403-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA179721
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: