Provider Demographics
NPI:1568440675
Name:VAN LOON, DERIN JOHN (OD)
Entity Type:Individual
Prefix:
First Name:DERIN
Middle Name:JOHN
Last Name:VAN LOON
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 1:213 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1985
Mailing Address - Country:US
Mailing Address - Phone:218-727-1004
Mailing Address - Fax:218-727-1525
Practice Address - Street 1:213 W 1ST ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1909
Practice Address - Country:US
Practice Address - Phone:218-727-1004
Practice Address - Fax:218-727-1525
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2650152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN637896000Medicaid
MN410002513Medicare PIN
U68089Medicare UPIN