Basic Information
| Provider Information | |||||||||
| NPI: | 1548242589 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAGGARD | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | ALLAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2625 E DIVISADERO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211431 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 45 E RIVER PARK PL W STE 104 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937201565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593200530 | ||||||||
| FaxNumber: | 5593200532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 11/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | A80229 | CA | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00A802290 | 05 | CA | MEDICAID |