Provider Demographics
NPI:1043391782
Name:MEAD, DEREK MALLORY (OD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:MALLORY
Last Name:MEAD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1321 N LOOP 1604 E STE 100A
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1438
Mailing Address - Country:US
Mailing Address - Phone:210-545-7067
Mailing Address - Fax:210-545-9629
Practice Address - Street 1:1321 N LOOP 1604 E STE 100A
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1438
Practice Address - Country:US
Practice Address - Phone:210-545-7067
Practice Address - Fax:210-545-9629
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6450TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist