Provider Demographics
NPI:1619923794
Name:DERBY, MARIZEL M (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIZEL
Middle Name:M
Last Name:DERBY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:977 ADDINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-1615
Mailing Address - Country:US
Mailing Address - Phone:801-599-7720
Mailing Address - Fax:
Practice Address - Street 1:7250 UNION PARK AVE
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1840
Practice Address - Country:US
Practice Address - Phone:801-255-0709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT372443-9934152W00000X
UT372443-8908152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU76410Medicare UPIN