Provider Demographics
NPI:1710295720
Name:DERHODGE, MICHAEL RYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RYAN
Last Name:DERHODGE
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 1:6091 S POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4899
Mailing Address - Country:US
Mailing Address - Phone:239-466-2020
Mailing Address - Fax:239-466-7150
Practice Address - Street 1:6091 S POINTE BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4899
Practice Address - Country:US
Practice Address - Phone:239-466-2020
Practice Address - Fax:239-466-7150
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4605152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL149YEOtherBC/BS OF FLORIDA
FLOPC4605OtherFLORIDA DEPARTMENT OF HEALTH LICENSE
DZ251VMedicare PIN
FLDZ251Medicare PIN
FLDZ251UMedicare PIN
FLDZ251TMedicare PIN