Healthcare Provider Details

I. General information

NPI: 1134386576
Provider Name (Legal Business Name): DEREK FAKHREDEAN AMANATULLAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PASTEUR DR
STANFORD CA
94305-2200
US

IV. Provider business mailing address

450 BROADWAY ST, MC 6342 PAVILION C, 4TH FLOOR
REDWOOD CITY CA
94063-3132
US

V. Phone/Fax

Practice location:
  • Phone: 650-723-4000
  • Fax:
Mailing address:
  • Phone: 650-723-2257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number106870
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number56793
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA105899
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberA105899
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: