Provider Demographics
NPI:1316409915
Name:BLUMENSTOCK, DEREK FRANCIS
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:FRANCIS
Last Name:BLUMENSTOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6716 S 34TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5436
Mailing Address - Country:US
Mailing Address - Phone:832-404-0099
Mailing Address - Fax:
Practice Address - Street 1:1501 PINE LAKE RD STE 1
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68512-3692
Practice Address - Country:US
Practice Address - Phone:402-421-7773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE1499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1499OtherSTATE ID #