Provider Demographics
NPI:1497766380
Name:COOMBS, DEREK L (OD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:L
Last Name:COOMBS
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 1:1653 16TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-1820
Mailing Address - Country:US
Mailing Address - Phone:805-528-6243
Mailing Address - Fax:805-543-4886
Practice Address - Street 1:592 CALIFORNIA BLVD
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1900
Practice Address - Country:US
Practice Address - Phone:805-543-4777
Practice Address - Fax:805-543-4886
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 7166 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0071660Medicaid
CAOP7166Medicare ID - Type Unspecified
CASD0071660Medicaid