Healthcare Provider Details

I. General information

NPI: 1083923585
Provider Name (Legal Business Name): DERRICK M. DESILVA, JR. MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 AMBOY AVE
EDISON NJ
08837-3579
US

IV. Provider business mailing address

2980 N BEVERLY GLEN CIR SUITE 301
LOS ANGELES CA
90077-1726
US

V. Phone/Fax

Practice location:
  • Phone: 732-738-8801
  • Fax:
Mailing address:
  • Phone: 310-474-9809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DERRICK M. DESILVA JR.
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 732-738-8801