Healthcare Provider Details

I. General information

NPI: 1407850498
Provider Name (Legal Business Name): LOUIS DEROUCHEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 BRUCE ST STE 500
YREKA CA
96097-3463
US

IV. Provider business mailing address

PO BOX 1126
YREKA CA
96097-1126
US

V. Phone/Fax

Practice location:
  • Phone: 530-842-3507
  • Fax: 530-842-9054
Mailing address:
  • Phone: 530-842-3507
  • Fax: 530-842-9054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA47801
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: