Healthcare Provider Details

I. General information

NPI: 1780511329
Provider Name (Legal Business Name): ERIKAH DISTAN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 CAMINO DEL RIO S STE 225
SAN DIEGO CA
92108-3756
US

IV. Provider business mailing address

2535 CAMINO DEL RIO S STE 225
SAN DIEGO CA
92108-3756
US

V. Phone/Fax

Practice location:
  • Phone: 619-320-4566
  • Fax:
Mailing address:
  • Phone: 619-320-4566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT297991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: