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General NPI Number Information
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NPI Number | 1336720804
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Entity Type | Individual
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Provider Name | DEREK ROGOZ
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Gender | Male
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Dates
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Enumeration Date | 04/16/2021
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Last Update Date | 02/08/2023
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Provider Practice Location Address
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Address Line | 301 N PRAIRIE AVE STE 202
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City | INGLEWOOD
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State | CA
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Zip | 90301-4509
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Country | US
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Telephone | 323-480-4075
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Fax |
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Provider Business Mailing Address
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Address Line | 301 N PRAIRIE AVE STE 202
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City | INGLEWOOD
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State | CA
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Zip | 90301-4509
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Country | US
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Telephone | 323-480-4075
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 59384
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License Number State | CA
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