Provider Demographics
NPI:1609083526
Name:DERBY, ROBERT WESSON (LO)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WESSON
Last Name:DERBY
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 LONGMEADOW ST
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-1351
Mailing Address - Country:US
Mailing Address - Phone:413-567-6242
Mailing Address - Fax:
Practice Address - Street 1:471 LONGMEADOW ST
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-1351
Practice Address - Country:US
Practice Address - Phone:413-567-6242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1477156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician