Provider Demographics
NPI:1215982970
Name:ALLEN, DERRICK ROSS (MD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:ROSS
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 34307
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-4307
Mailing Address - Country:US
Mailing Address - Phone:888-727-1270
Mailing Address - Fax:877-883-5176
Practice Address - Street 1:501 WASHINGTON ST
Practice Address - Street 2:510
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2231
Practice Address - Country:US
Practice Address - Phone:619-849-1729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA698402085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A698400Medicaid
CAH53717Medicare UPIN
CAAW145YMedicare PIN
CA00A698402Medicare ID - Type Unspecified
CA00A698400Medicaid
CAAW145XMedicare PIN
H53717Medicare UPIN
CAAW145VMedicare PIN