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NPI Code Detail

MEDICARE: DR. DONALD DEAN DERRYBERRY JR. O.D.

MEDICARE: DR. DONALD DEAN DERRYBERRY JR. 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
1152W00000XOptometrist4584TGTX

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
18F21032OTHERTXMEDICARE PTAN INDIVIDUAL

General Provider Information

NPI Number : 1194722082
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. DONALD DEAN DERRYBERRY JR. O.D.
Provider Business Mailing Address
First Line : 18170 DALLAS PKWY
Second Line : SUITE 402
City : DALLAS
State : TX
Zip : 75287-7137
Country : US
Telephone Number : 972-931-2020
Fax Number :
Provider Business Practice Location Address
First Line : 18170 DALLAS PKWY
Second Line : SUITE 402
City : DALLAS
State : TX
Zip : 75287-7137
Country : US
Telephone Number : 972-931-2020
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/07/2005
Last Update Date : 04/20/2009

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