MEDICARE: MRS. MIKLA NINA DERLET MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	A77577	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154323715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MIKLA NINA DERLET MD

Provider Business Mailing Address
First Line	:	2516 STOCKTON BLVD
Second Line	:	DEPARTMENT OF PEDIATRICS
City	:	SACRAMENTO
State	:	CA
Zip	:	95817-2208
Country	:	US
Telephone Number	:	916-734-5387
Fax Number	:	916-456-2236

Provider Business Practice Location Address
First Line	:	2516 STOCKTON BLVD
Second Line	:	DEPARTMENT OF PEDIATRICS
City	:	SACRAMENTO
State	:	CA
Zip	:	95817-2208
Country	:	US
Telephone Number	:	916-734-5387
Fax Number	:	916-456-2236

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	05/09/2016

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