MEDICARE: DEREK GAGNON M.D.

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	207Q00000X	Family Medicine Physician	20565	SC

General Provider Information

NPI Number	:	1235108010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK GAGNON M.D.

Provider Business Mailing Address
First Line	:	8301 RIO SAN DIEGO DR
Second Line	:	#21
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-5686
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3985 CUMMINGS RD
Second Line	:	STE 4
City	:	SAN DIEGO
State	:	CA
Zip	:	92136-5218
Country	:	US
Telephone Number	:	619-572-8192
Fax Number	:

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

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	07/08/2007

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