Provider Demographics
NPI:1174836431
Name:AMES, DEREK BUSENBARK (OD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:BUSENBARK
Last Name:AMES
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 1:2610 PIONEER RD
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7442
Mailing Address - Country:US
Mailing Address - Phone:435-674-9770
Mailing Address - Fax:435-674-9771
Practice Address - Street 1:2610 PIONEER RD
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7442
Practice Address - Country:US
Practice Address - Phone:435-674-9770
Practice Address - Fax:435-674-9771
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7693840-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist