Provider Demographics
NPI:1063968097
Name:ESTIFANOS, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:ESTIFANOS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 OWENSMOUTH AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-4255
Mailing Address - Country:US
Mailing Address - Phone:818-647-2653
Mailing Address - Fax:
Practice Address - Street 1:6800 OWENSMOUTH AVE STE 160
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-4255
Practice Address - Country:US
Practice Address - Phone:818-647-2653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner