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General NPI Number Information
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NPI Number | 1285779140
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Entity Type | Organization
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Legal Business Name | DARYN W DERSTINE OD PC
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 12000 SE 82ND AVE 1008
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City | PORTLAND
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State | OR
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Zip | 97266-7721
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Country | US
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Telephone | 503-654-6217
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Fax | 503-654-9335
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Provider Business Mailing Address
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Address Line | 12000 SE 82ND AVE 1008
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City | PORTLAND
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State | OR
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Zip | 97086
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Country | US
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Telephone | 503-654-6217
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Fax | 503-654-9335
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DARYN W DERSTINE
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Credential | O.D.
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Telephone | 503-654-6217
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2773ATI
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License Number State | OR
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