Provider Demographics
NPI:1114353232
Name:BLACK, DEREK ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:ALAN
Last Name:BLACK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1211 BALD RIDGE MARINA RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-8484
Mailing Address - Country:US
Mailing Address - Phone:470-239-6625
Mailing Address - Fax:470-239-6626
Practice Address - Street 1:1211 BALD RIDGE MARINA RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-8484
Practice Address - Country:US
Practice Address - Phone:470-239-6625
Practice Address - Fax:470-239-6626
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002922152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist