Provider Demographics
NPI:1558356980
Name:DERR, KIRSTEN P (OD)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:P
Last Name:DERR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 TALISMAN DR UNIT B4
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-9171
Mailing Address - Country:US
Mailing Address - Phone:970-731-4347
Mailing Address - Fax:970-731-4347
Practice Address - Street 1:190 TALISMAN DR UNIT B4
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-9171
Practice Address - Country:US
Practice Address - Phone:970-731-4347
Practice Address - Fax:970-731-4772
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM418152W00000X
COOPT.0003642152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP00151450OtherRRB MEDICARE RAILROAD
AZ881369Medicaid
NML3596Medicaid
CO9000196852Medicaid
NMNM02P497OtherBC BS OF NM
NMP00151450OtherRRB MEDICARE RAILROAD