Provider Demographics
NPI:1619326337
Name:BAILEY, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:BAILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 S WOODSCREST DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5314
Mailing Address - Country:US
Mailing Address - Phone:812-332-2020
Mailing Address - Fax:
Practice Address - Street 1:322 S WOODSCREST DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5314
Practice Address - Country:US
Practice Address - Phone:812-332-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003959A152W00000X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision