Provider Demographics
NPI:1215254750
Name:ULVILA, DEREK DANIEL
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:DANIEL
Last Name:ULVILA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 ARCH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-1326
Mailing Address - Country:US
Mailing Address - Phone:347-770-5891
Mailing Address - Fax:314-528-9061
Practice Address - Street 1:133 ARCH ST STE 4
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-1326
Practice Address - Country:US
Practice Address - Phone:347-770-5891
Practice Address - Fax:314-528-9061
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA119052208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty