Provider Demographics
NPI:1669490686
Name:DERSTINE, DARYN W (OD)
Entity Type:Individual
Prefix:DR
First Name:DARYN
Middle Name:W
Last Name:DERSTINE
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 1:6539 SE MILWAUKIE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-5519
Mailing Address - Country:US
Mailing Address - Phone:503-236-6008
Mailing Address - Fax:503-236-2057
Practice Address - Street 1:6539 SE MILWAUKIE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5519
Practice Address - Country:US
Practice Address - Phone:503-236-6008
Practice Address - Fax:503-236-2057
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2773ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR112980Medicare ID - Type UnspecifiedGROUP ID (CORPORATATION)
ORU84765Medicare UPIN
ORR111300Medicare ID - Type UnspecifiedPERSONAL ID