Healthcare Provider Details

I. General information

NPI: 1255795217
Provider Name (Legal Business Name): ANGELINE DERHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5717 BALCONES DR
AUSTIN TX
78731-4203
US

IV. Provider business mailing address

5717 BALCONES DR
AUSTIN TX
78731-4203
US

V. Phone/Fax

Practice location:
  • Phone: 512-327-7000
  • Fax: 512-314-1661
Mailing address:
  • Phone: 512-314-1613
  • Fax: 512-314-1661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberS4460
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: