Healthcare Provider Details

I. General information

NPI: 1457413411
Provider Name (Legal Business Name): MR. DEREK ANTAWN ALSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

U S COAST GUARD 2100 2ND ST SW SUITE 5314
WASHINGTON DC
20593-0001
US

IV. Provider business mailing address

U S COAST GUARD 2100 2ND ST SW SUITE 5314
WASHINGTON DC
20593-0001
US

V. Phone/Fax

Practice location:
  • Phone: 504-253-6506
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number24720000X
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: