Healthcare Provider Details

I. General information

NPI: 1861832230
Provider Name (Legal Business Name): DEREK GLEN MCALLISTER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2428 SANTA MONICA BLVD
SANTA MONICA CA
90404-2045
US

IV. Provider business mailing address

300 PASTEUR DR
STANFORD CA
94305-2200
US

V. Phone/Fax

Practice location:
  • Phone: 310-315-1000
  • Fax:
Mailing address:
  • Phone: 650-723-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number5101020333
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number20A16474
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number20A16474
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: