Provider Demographics
NPI:1699978346
Name:DERDERIAN, COURTNEY KOWALCZYK (MD)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:KOWALCZYK
Last Name:DERDERIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:ANNE
Other - Last Name:KOWALCZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1935 MEDICAL DISTRICT DR
Mailing Address - Street 2:DEPARTMENT OF ANESTHESIOLOGY
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7701
Mailing Address - Country:US
Mailing Address - Phone:214-456-6393
Mailing Address - Fax:214-456-7232
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:DEPARTMENT OF ANESTHESIOLOGY
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-456-6393
Practice Address - Fax:214-456-7232
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2708207LP3000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3054389 01Medicaid
TX3054389 01Medicaid