Provider Demographics
NPI:1467504803
Name:TAGUCHI, DERIN KEN (OD)
Entity Type:Individual
Prefix:DR
First Name:DERIN
Middle Name:KEN
Last Name:TAGUCHI
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 1:15407 MAIN ST
Mailing Address - Street 2:STE E103
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-7375
Mailing Address - Country:US
Mailing Address - Phone:425-232-7164
Mailing Address - Fax:
Practice Address - Street 1:15407 MAIN ST
Practice Address - Street 2:# E103
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-7375
Practice Address - Country:US
Practice Address - Phone:425-771-8825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3686152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist