Healthcare Provider Details

I. General information

NPI: 1275989717
Provider Name (Legal Business Name): DEREK IZAK BRINK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 05/26/2022
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3190 CHURN CREEK RD
REDDING CA
96002-2122
US

IV. Provider business mailing address

2139 VIENNA WAY
REDDING CA
96003-9324
US

V. Phone/Fax

Practice location:
  • Phone: 530-223-2500
  • Fax:
Mailing address:
  • Phone: 530-701-2875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number20A18109
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: