MEDICARE: DERRON TIMOTHY LEE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	12387T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11620	OTHER	CA	MESC
2	CA2387	OTHER	CA	EYEMED

General Provider Information

NPI Number	:	1144313552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERRON TIMOTHY LEE O.D.

Provider Business Mailing Address
First Line	:	2321 W MARCH LN STE A
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-5265
Country	:	US
Telephone Number	:	209-986-1880
Fax Number	:	209-957-8077

Provider Business Practice Location Address
First Line	:	2321 W MARCH LN
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-5261
Country	:	US
Telephone Number	:	209-986-1880
Fax Number	:	209-957-8077

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2006
Last Update Date	:	09/27/2024

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