Provider Demographics
NPI:1255824306
Name:PRICE, DEREK (OD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:PRICE
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 1:520 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-1415
Mailing Address - Country:US
Mailing Address - Phone:260-563-0884
Mailing Address - Fax:260-563-3284
Practice Address - Street 1:506 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-1961
Practice Address - Country:US
Practice Address - Phone:765-662-6648
Practice Address - Fax:765-662-6250
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004094A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist