Provider Demographics
NPI:1376506063
Name:SPURLOCK, DERRELL R II (OD)
Entity Type:Individual
Prefix:
First Name:DERRELL
Middle Name:R
Last Name:SPURLOCK
Suffix:II
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 1:421 HOMER RD
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-2933
Mailing Address - Country:US
Mailing Address - Phone:318-377-4246
Mailing Address - Fax:318-377-4123
Practice Address - Street 1:421 HOMER RD
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055
Practice Address - Country:US
Practice Address - Phone:318-377-4246
Practice Address - Fax:318-377-4123
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1076073T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1903540Medicaid
LA0176470001Medicare NSC
T97034Medicare UPIN
LA1903540Medicaid