Healthcare Provider Details

I. General information

NPI: 1730113291
Provider Name (Legal Business Name): GABRIEL DERY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28521 PASEO DIANA
SAN JUAN CAPISTRANO CA
92675-2905
US

IV. Provider business mailing address

28521 PASEO DIANA
SAN JUAN CAPISTRANO CA
92675-2905
US

V. Phone/Fax

Practice location:
  • Phone: 949-275-7539
  • Fax: 949-496-2034
Mailing address:
  • Phone: 949-275-7539
  • Fax: 949-496-2034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number5841T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: