=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538145594
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD JOSEPH DERIVAUX MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2005
-----------------------------------------------------
Last Update Date | 05/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 MERIDIAN ST N STE 200
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35801-4720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-705-3937
-----------------------------------------------------
Fax | 256-533-3213
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1013 CORONADO AVE SE
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35802-2650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-882-1083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 00014911
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------