Provider Demographics
NPI:1376543801
Name:PRESTRIDGE, DARRELL SCOTT (DO)
Entity Type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:SCOTT
Last Name:PRESTRIDGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 531326
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35253-1326
Mailing Address - Country:US
Mailing Address - Phone:205-621-3437
Mailing Address - Fax:205-621-8550
Practice Address - Street 1:2122 OLD MONTGOMERY HWY
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-1138
Practice Address - Country:US
Practice Address - Phone:205-621-3437
Practice Address - Fax:205-621-8550
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD0502207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000094295Medicaid
AL515-33912OtherBC BS OF AL
AL000094295Medicaid
AL515-11433OtherBC BS OF AL
AL515-33813OtherBC BS OF AL
G58319Medicare UPIN