Healthcare Provider Details

I. General information

NPI: 1215466008
Provider Name (Legal Business Name): DEREK HENNIG OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 06/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 18TH ST
CHARLESTON IL
61920-3607
US

IV. Provider business mailing address

1700 18TH ST
CHARLESTON IL
61920-3607
US

V. Phone/Fax

Practice location:
  • Phone: 217-345-6600
  • Fax: 217-345-6622
Mailing address:
  • Phone: 217-345-6600
  • Fax: 217-345-6622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046011094
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: