Provider Demographics
NPI:1871877134
Name:DERIDDER, PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:DERIDDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PAUL
Other - Middle Name:
Other - Last Name:DERIDDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4108 RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2915
Mailing Address - Country:US
Mailing Address - Phone:714-345-5887
Mailing Address - Fax:949-548-1994
Practice Address - Street 1:4108 RIVER AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-2915
Practice Address - Country:US
Practice Address - Phone:714-345-5887
Practice Address - Fax:949-548-1994
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33885208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology