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General NPI Number Information
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NPI Number | 1356686976
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Entity Type | Organization
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Legal Business Name | JOHN C. DERICKSON OD, PA
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Dates
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Enumeration Date | 12/07/2012
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Last Update Date | 12/07/2012
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Provider Practice Location Address
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Address Line | 8771 PERIMETER PARK CT SUITE 101
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City | JACKSONVILLE
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State | FL
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Zip | 32216-6396
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Country | US
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Telephone | 904-997-8585
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Fax |
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Provider Business Mailing Address
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Address Line | 8771 PERIMETER PARK CT SUITE 101
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City | JACKSONVILLE
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State | FL
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Zip | 32216-6396
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Country | US
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Telephone | 904-997-8585
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN CHRISTIAN DERICKSON
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Credential | O.D.
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Telephone | 904-997-8585
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | OPC3107
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License Number State | FL
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