Provider Demographics
NPI:1477621191
Name:DERZAY, MICHAEL EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:DERZAY
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 1:9911 N NEVADA ST STE B
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1298
Mailing Address - Country:US
Mailing Address - Phone:509-484-5710
Mailing Address - Fax:509-487-1000
Practice Address - Street 1:9911 N NEVADA ST STE B
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1298
Practice Address - Country:US
Practice Address - Phone:509-484-5710
Practice Address - Fax:509-487-1000
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003454152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031789Medicaid
WA2031789Medicaid
WA8856502Medicare ID - Type Unspecified