Provider Demographics
NPI:1619032083
Name:VERDERAME, PHILIP JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:JOSEPH
Last Name:VERDERAME
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PHILIP
Other - Middle Name:J
Other - Last Name:VERDERAME
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2020 COFFEE RD
Mailing Address - Street 2:SUITE H-1
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2427
Mailing Address - Country:US
Mailing Address - Phone:209-522-1023
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:2020 COFFEE RD
Practice Address - Street 2:SUITE H-1
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2427
Practice Address - Country:US
Practice Address - Phone:209-522-1023
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA354502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA35450OtherSTATE LICENSE NUMBER
CAA35450OtherSTATE LICENSE NUMBER