Healthcare Provider Details

I. General information

NPI: 1457883605
Provider Name (Legal Business Name): DEREK GILBERT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 09/21/2023
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 TESCONI CIR STE B
SANTA ROSA CA
95401-4691
US

IV. Provider business mailing address

480 TESCONI CIR STE B
SANTA ROSA CA
95401-4691
US

V. Phone/Fax

Practice location:
  • Phone: 707-206-7268
  • Fax: 707-206-7254
Mailing address:
  • Phone: 707-206-7268
  • Fax: 707-206-7254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR4404
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA173547
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: