MEDICARE: DR. ANGELA ELLIS DERBES 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	152WP0200X	Pediatric Optometrist	5117TG	TX

General Provider Information

NPI Number	:	1629310776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANGELA ELLIS DERBES O.D.

Provider Business Mailing Address
First Line	:	4735 JOHNSON CREEK LOOP
Second Line	:
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-3890
Country	:	US
Telephone Number	:	979-777-9589
Fax Number	:

Provider Business Practice Location Address
First Line	:	4735 JOHNSON CREEK LOOP
Second Line	:
City	:	COLLEGE STATION
State	:	TX
Zip	:	77845-3890
Country	:	US
Telephone Number	:	979-777-9589
Fax Number	:

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

Provider Enumeration Date	:	03/26/2013
Last Update Date	:	03/26/2013

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