Healthcare Provider Details

I. General information

NPI: 1851747901
Provider Name (Legal Business Name): DEREK SUSUMU MORIYAMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2016
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15000 KENSINGTON PARK DR STE 170
TUSTIN CA
92782-1836
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 714-477-8300
  • Fax: 714-477-8301
Mailing address:
  • Phone: 323-442-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberA168883
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: