Healthcare Provider Details

I. General information

NPI: 1609889310
Provider Name (Legal Business Name): DEIDRA MARIE CASAUS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 S CAMINO DEL PUEBLO STE E
BERNALILLO NM
87004-6173
US

IV. Provider business mailing address

3566 WHITE HORSE DR SE
RIO RANCHO NM
87124-3676
US

V. Phone/Fax

Practice location:
  • Phone: 505-771-3937
  • Fax: 505-771-1282
Mailing address:
  • Phone: 505-771-3937
  • Fax: 505-771-1282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number408
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: