Provider Demographics
NPI:1619296399
Name:DERRELL R. SPURLOCK, II, O.D.
Entity Type:Organization
Organization Name:DERRELL R. SPURLOCK, II, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CLERK
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:THURMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-377-4246
Mailing Address - Street 1:421 HOMER RD
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-2933
Mailing Address - Country:US
Mailing Address - Phone:318-377-4246
Mailing Address - Fax:318-377-4123
Practice Address - Street 1:421 HOMER RD
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-2933
Practice Address - Country:US
Practice Address - Phone:318-377-4246
Practice Address - Fax:318-377-4123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-20
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1076-073T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1376506063Medicare NSC