Provider Demographics
NPI:1114365129
Name:EVANS, DEREK M (OD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:M
Last Name:EVANS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 TEWNING RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2639
Mailing Address - Country:US
Mailing Address - Phone:540-371-2020
Mailing Address - Fax:540-373-0141
Practice Address - Street 1:101 TEWNING RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2639
Practice Address - Country:US
Practice Address - Phone:757-229-1131
Practice Address - Fax:757-229-1586
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002247152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist