Provider Demographics
NPI:1356686976
Name:JOHN C. DERICKSON OD, PA
Entity Type:Organization
Organization Name:JOHN C. DERICKSON OD, PA
Other - Org Name:DERICKSON VISION CONSULTANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:DERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-997-8585
Mailing Address - Street 1:8771 PERIMETER PARK CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6396
Mailing Address - Country:US
Mailing Address - Phone:904-997-8585
Mailing Address - Fax:
Practice Address - Street 1:8771 PERIMETER PARK CT
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6396
Practice Address - Country:US
Practice Address - Phone:904-997-8585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3107152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE1327Medicare UPIN