Provider Demographics
NPI:1619023678
Name:BUB, DARRICK SHAWN (OD)
Entity Type:Individual
Prefix:DR
First Name:DARRICK
Middle Name:SHAWN
Last Name:BUB
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 1:10411 W FAIRMONT PKWY
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:TX
Mailing Address - Zip Code:77571-6014
Mailing Address - Country:US
Mailing Address - Phone:281-991-6774
Mailing Address - Fax:832-201-9836
Practice Address - Street 1:10411 W FAIRMONT PKWY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:TX
Practice Address - Zip Code:77571-6014
Practice Address - Country:US
Practice Address - Phone:281-991-6774
Practice Address - Fax:832-201-9836
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5614TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U80162Medicare UPIN
TX81284EMedicare ID - Type Unspecified