Provider Demographics
NPI:1679749683
Name:RAPTIS, DERRICK (MD)
Entity type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:
Last Name:RAPTIS
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 1:840 TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1488
Practice Address - Street 1:1940 N ORANGE GROVE AVE STE A
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3002
Practice Address - Country:US
Practice Address - Phone:909-865-6900
Practice Address - Fax:909-865-6300
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117405207R00000X, 207RC0200X, 207RP1001X
NY249226207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFW009ZMedicare PIN
CAFW009YMedicare PIN